Question

1. You are the health information manager at a local hospital. A physician on the medical staff does not understand how to add H&P notes to a patient’s EHR. He explains that he “always used to handwrite the H&P.” You explain to the physician that he can no longer handwrite his H&P notes, and you give him two options of how he can add his H&P notes to the EHR. Describe these two options.

2. You are a laboratory manager at a local hospital. Your laboratory systems can interface with the hospital’s EHR system to automatically provide test results. However, there are times when this process does not function properly and results have to be entered manually. As the laboratory manager, you want to develop a procedure for doing this. What steps might you include in this procedure? Write a one-page procedure for manually entering laboratory results into the hospital’s EHR system when the laboratory computer cannot automatically transfer the laboratory results to the hospital’s EHR system.

Answer 1

1)PC based documentation (CBD) frameworks, there is a developing accentuation on organizing clinical notes to help reusing information for ensuing errands. Nonetheless, clinical documentation stays one of the most testing regions for EHR framework advancement and selection. The current original copy depicts the Vanderbilt involvement in actualizing clinical documentation with an EHR framework.

2)

*Every EHR system provide a platform of streamline workflow like standardized laboratory orderings, guidelines, deliver decision alerts and test.

*search functionallyis found in most EHR implementation that permits providers to rapidly search for a laboratory order in a given list of laboratory test.

*With search, clinicians enter search terms and the system returns a list of matching tests.

* In addition to searching for laboratory tests, EHRs typically allow providers to create personalized preference lists with tests they find particularly helpful or order most frequently.

*Further, standardized order sets provided in most EHR implementations offer an opportunity for the system to guide order selection by clinicians