Managing Computers in the Medical Office and EMR Part 2

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The “O” in SOAP notes is for

This was developed by Dr. Lawrence Weed in 1970 and is used to identify patient problems and chart by those problem

Everything that is done during a patient’s medical visit, ordered over the telephone, or discussed with a patient by telephone or e-mail must not be documented in the medical record

POMR notes refer to

EMR’s can help remind patients of the need to schedule

Using electronic medical records has additional benefits including electronic signatures, avoiding medical errors, saving time, facilitating patient health maintenance, immediate diagnostic test results, marketing, and communicating online

The most recent information is seen first in each section of the medical record. This method makes it complicated to identify and locate past medical problems, treatments, and results

To remain in compliance with HIPAA regulations, medical offices must use data backup systems to safeguard the information contained on office computer systems, including patient medical records