Data Types in the Medical Record

2011 ◽  
pp. 17-31
Author(s):  
Prakash M. Nadkarni
Keyword(s):  
Medical Record ◽  
Data Types

scholarly journals Use of more than one electronic medical record system within a single health care organization

2012 ◽  
Vol 03 (04) ◽  
pp. 462-474 ◽  
Author(s):  
J. Fellner ◽  
C. Dugowson ◽  
D. Liebovitz ◽  
G. Fletcher ◽  
T. Payne
Keyword(s):  
Health Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Health Care Organization ◽  
Electronic Medical Record System ◽  
Healthcare Organization ◽  
Care Organization ◽  
Data Types ◽  
Record System ◽  
Medical Record System

SummaryHealthcare organizations vary in the number of electronic medical record (EMR) systems they use. Some use a single EMR for nearly all care they provide, while others use EMRs from more than one vendor. These strategies create a mixture of advantages, risks and costs. Based on our experience in two organizations over a decade, we analyzed use of more than one EMR within our two health care organizations to identify advantages, risks and costs that use of more than one EMR presents. We identified the data and functionality types that pose the greatest challenge to patient safety and efficiency. We present a model to classify patterns of use of more than one EMR within a single healthcare organization, and identified the most important 28 data types and 4 areas of functionality that in our experience present special challenges and safety risks with use of more than one EMR within a single healthcare organization. The use of more than one EMR in a single organization may be the chosen approach for many reasons, but in our organizations the limitations of this approach have also become clear. Those who use and support EMRs realize that to safely and efficiently use more than one EMR, a considerable amount of IT work is necessary. Thorough understanding of the challenges in using more than one EMR is an important prerequisite to minimizing the risks of using more than one EMR to care for patients in a single healthcare organization. Citation: Payne T, Fellner J, Dugowson C, Liebovitz D, Fletcher G. Use of more than one electronic medical record system within a single health care organization. Appl Clin Inf 2012; 3: 462–474http://dx.doi.org/10.4338/ACI-2012-10-RA-0040

More Than Just a Medical Record

ASHA Leader ◽  
2013 ◽  
Vol 18 (8) ◽  
pp. 12-12 ◽  
Keyword(s):  
Medical Record

More Than Just a Medical Record

Coding for Evaluation and Treatment

2008 ◽  
Vol 18 (1) ◽  
pp. 9-20 ◽  
Author(s):  
Mark Kander ◽  
Steve White
Keyword(s):  
Medical Record ◽  
Treatment Session ◽  
Accurate Diagnosis ◽  
Third Party ◽  
Speech Language Pathologists ◽  
Adequate Information ◽  
Diagnosis Codes ◽  
Coding Rules ◽  
Procedure Codes ◽  
The Web

Abstract This article explains the development and use of ICD-9-CM diagnosis codes, CPT procedure codes, and HCPCS supply/device codes. Examples of appropriate coding combinations, and Coding rules adopted by most third party payers are given. Additionally, references for complete code lists on the Web and a list of voice-related CPT code edits are included. The reader is given adequate information to report an evaluation or treatment session with accurate diagnosis, procedure, and supply/device codes. Speech-language pathologists can accurately code services when given adequate resources and rules and are encouraged to insert relevant codes in the medical record rather than depend on billing personnel to accurately provide this information. Consultation is available from the Division 3 Reimbursement Committee members and from [email protected] .

Quality control and the medical record

1971 ◽  
Vol 127 (1) ◽  
pp. 101-105 ◽  
Author(s):  
L. L. Weed
Keyword(s):  
Quality Control ◽  
Medical Record

Identifying the Needs and Benefits of an Electronic Medical Record (EMR) System through Research, Development, and Implementation

2010 ◽  
Author(s):  
Arif Ahmed ◽  
Kimona Kousins ◽  
Ritika Jhangiani ◽  
Shinjini Kar ◽  
Michael Lewis
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Research Development
Sign in / Sign up

Export Citation Format

Share Document