The following can be documented as part of the EMR

The following can be documented as part of the EMR

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

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

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

Electronic medical records are gaining popularity over conventional paper files because they offer

Having electronic information available is especially helpful for patients when they travel or need to seek emergency care with someone other than their primary care providers

Information found in the medical records will include

Information contained in the medical record will include

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

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

These records follows the patient over a period of time, with each visit consisting of a new entry by date, rather than by symptoms or diagnosis

SOAP notes refer to

POMR notes refer to

The “O” in SOAP notes is for

Subjective symptoms are ones that can be verified through testing and assessment

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

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