Understanding Electronic Health Records 1
HCS/120 Version 5
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Understanding Electronic Health Records
 Write each term’s definition as used in health care. You must define the term in your own words;
do not simply copy the definition from a textbook or other source.
 Provide an explanation that illustrates the purpose or importance of the identified term as it
relates to Electronic Health Records.
 Cite at least 3 peer-reviewed, scholarly, or similar references.
Term Definition in your own words (45
to 90 words).
Technology
Meaningful Use This is a U.S. government program
implemented to incentivize
physicians to use electronic health
records to share store and share
information in specific ways to
demonstrate meaningful use of the
electronic record. Physicians who do
not participate in the meaningful use
program receive reduced Medicare
or Medicaid reimbursements for their
service as a penalty (Athenahealth,
2018).
Health Information Health Information Exchange is part
Exchange of the meaningful use standard. It
allows doctors, pharmacists, nurse
and other clinicians to securely,
quickly and efficiently access and
share complete and up to date
patient information (The Office of the
National Coordinator for Health
Information Technology, 2018).
Clinical
Patient Problem (Concern) The patient problem is the issue or
concern that the patient is having
which led him or her to seek medical
care. The patient problem consists
of the patient’s subjective complaints
for which he or she is seeking
examination or treatment.
Copyright © 2017 by University of Phoenix. All rights reserved.
Explain the purpose and
importance of the term to
Electronic Health Records (45 to
90 words).
The meaningful use program’s
stated purpose is to reduce cost
and improve the quality and
efficiency of healthcare in the US
by facilitating the transition from
paper charts to electronic health
records, creating a nationwide,
electronic healthcare infrastructure
and widespread use of electronic
health records (Athenahealth,
2018).
This term is one of the greatest
benefits of HER. The Health
Information Exchange
standardizes data and integrates it
into the patients EHR where it
becomes available for directed
exchange, query-based exchange,
and consumer medicated
exchange (The Office of the
National Coordinator for Health
Information Technology, 2018).
EHRs organize patient complaints
into problems lists. The problem
list is a list of illnesses and injuries,
affecting the health of a patient,
including the date and time of
occurrence and the problem
resolution. By generating problem
lists and allowing all clinicians to
go to a single location to access
this comprehensive list, EHRs
promote continuity of care (AHIMA
Work Group, 2011)

Nursing Assessment
Physical Exam (Patient
History, Review of
Symptoms, Allergies)
Diagnosis
Procedure Preformed
Prognosis
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Understanding Electronic Health Records
The nursing assessment is a
systematic and thorough acquisition
of information related to the patient’s
current physical, mental, emotional
and social status. This information is
used as baseline and to determine
efficacy of subsequent care plans.
The physical exam takes place when
a physician auscultates, palpates,
percusses, and/or visually examines
the body systematically for
abnormalities. Special attention is
paid to any areas where the patient
reports symptoms as well as any
associated areas. Physical exam
supports patient history.
Diagnosis is a determination of
specific illness, injury or condition
base on assessment and exam
finding as well as subjective data
provided by the patient. Diagnosis
are standardized groups of
coexisting symptoms within the
patient’s physiology or psychology.
The procedure performed is the
action that performed on the patient
for the purpose of diagnosing or
treating a condition.
A prognosis the doctors
determination of the anticipated
course of an illness and the
likelihood of recovery or good
outcome.
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By using electronic Nurse
Screening Assessments that
organize and categorize
assessment data, EHR is able to
analyze assessment data and
detect changes in this data early.
Electronic nursing assessment as
a part of EHR enhances
preventative care and supports
early intervention when necessary
(Muge Capan, 2017).
EHRs assist doctors in analyzing
physical exam data by comparing
data to normal values and patient
trends. Patient allergies are
automatically cross referenced
with new medication. New
medications are cross referenced
with each other and flagged for
potential negative drug interactions
(The Office of the National
Coordinator for Health Information
Technology, 2018).
EHR’s improve physician’s ability
to diagnose disease by given the
physician access to the patient’s
full medical history not just his or
her history with that physician.
Because the information contained
in EHRs in comprehensive,
doctors can make more accurate
diagnoses faster and with fewer
errors (The Office of the National
Coordinator for Health Information
Technology, 2018).
EHRs using a standardized
system of codes to communicate
which procedures are performed
for other clinicians and for
insurance companies for billing
purposes. Detailed information
about any surgeries and procedure
the patient has undergone (The
Office of the National Coordinator
for Health Information Technology,
2018).
EHRs can improve patient
prognosis by reducing chances of
medical errors and assisting
doctors in making early diagnoses.
By giving doctors access to
comprehensive health information,
patients receive higher quality
 Understanding Electronic Health Records
Discharge Plan (E- Discharging is the process of
prescribing) preparing the patient to transition
from a healthcare inpatient setting
back to their place of residence or
releasing a patient from their current
treatment plan. E-prescribing is the
process of physicians typing
prescriptions into software that
allows them to electronically submit
the prescription to the pharmacy.
Patient Education Patient education is any teaching
that is done by the clinician. Patients
may require teaching on a variety of
aspects related to their treatment or
diagnosis. Some examples included
how to care for an injury, manage a
new diagnosis of chronic or acute
illness, application or care of medical
device, administration of new
medication, disease process,
interpretation of lab results, safety,
nutrition or therapeutic dietary
requirements.
Administration
Patient Demographic Information describing specific
characteristics of the patient are
called the patient’s demographics.
Patient demographics include,
gender, race, ethnicity, language,
income level, marital status and
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HCS/120 Version 5
medical care and thereby
improving patient prognosis (The
Office of the National Coordinator
for Health Information Technology,
2018).
EHR facilitate e-prescribing which
makes it easier for doctors to
prescribe medication and allows
patients to receive and begin
taking their prescribed medications
sooner. HER increase medication
compliance because patients no
longer need to transport paper
prescriptions to pharmacies and
wait for them to be filled. EHRs
reduce prescription errors by
requiring all necessary information
be present prior to transmission.
Software can evaluate drug
interaction and drug allergies at
the time of the order, identify
duplicate medication orders and
track prescription fulfillment
(Benefits of e-prescribing, 2018)
Patient education and engagement
is a required use of EHRs per the
Meaningful use criteria. EHRs
generate patient office visit
summaries to help patients
understand and participate in their
own care. EHRs generate
medication lists, test results and
problem lists in lay terms because
patients who have greater
understanding of their medication
and test results have more
medication and treatment
compliance. EHRs also include
pertinent information on the
patient’s specific diagnosis so that
the patient can learn about their
illness and treatment. This written
information backs up the oral
reminders and teaching given by
the practitioner (Krames Staywell,
2017).
EHRs manage and store patient
demographic information. The
EHR is then able to track
demographic information, identify
clinically relevant demographic
information and a makes that

Insurance Information
Advanced directives
References:
Copyright © 2017 by University of Phoenix. All rights reserved.
Understanding Electronic Health Records
occupation are included in patient
demographics.
The insurance information states the
name location and contact
information for the insurance
company that will be paying for
medical care. It may also include
copay amounts and payment
information such as what percentage
of costs are covered by the
insurance provider.
Advanced directives are prewritten
instructions for what level of care a
patient wants to receive should he or
she be rendered unconscious or
otherwise unable to make medical
decisions.
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information accessible to all
clinicians who care for the patient
(The Office of the National
Coordinator for Health Information
Technology, 2018).
The insurance information in EHRs
helps clinicians verify insurance
information at the time services
are rendered. EHRs are also used
to track insurance enrollment and
help patients keep up with
coverage renewal. They also
reduce late insurance filing.
Additionally, software will prompt
doctors if they need advance
beneficiary notice, are performing
a test to frequently thereby
reducing instances of claim denials
and reduce time and labor
required for billing (The Office of
the National Coordinator for Health
Information Technology, 2018)
It is vitally important that advanced
directives follow a patient
wherever he or she receives care.
In theory EHR should allow this to
occur seamlessly regardless of the
patient’s level of consciousness.
Also, advance directives can be
updated quickly and accessed by
all clinicians who provide care for
the patient. Unfortunately, many
advanced directives have been
overlooked or ignored because
clinicians have not been able to
locate them in the EHR due to
inconsistent location. While the
EHR may indicate the existence of
advance directives, the advanced
directive itself is not always stored
in the patient’s EHR. A recent
study revealed that 27% of
physicians and 73% of medical
assistants could not located a
patient’s advanced directives
within 2 minutes. This study
highlights the need for a single-
location feature for all EHRs for
advanced directives (Marianne
Turley, 2016)
 Understanding Electronic Health Records 5
HCS/120 Version 5

AHIMA Work Group. (2011). Problem list Guidance in the EHR. Journal of AHIMA , 52-58.

Athenahealth. (2018). What is Meaningful Use. Retrieved from Meaningful Use Knowledge Hub:
https://www.athenahealth.com/knowledge-hub/meaningful-use/what-is-meaningful-use

Benefits of e-prescribing. (2018). Retrieved from DrFirst.com: https://www.drfirst.com/benefits-of-e-

prescribing/

Krames Staywell. (2017). Meaningful Use Requirements for Patient Education. Retrieved from
healthcommunications.org: http://www.healthcommunications.org/resources/meaningful_use.pdf

Marianne Turley, S. W. (2016). Impact of Care Directives Activity Tab in the Electronic Record on
Documentation of Advanced Care Planning. The Permenente Journal, 43-48.

Muge Capan, P. W. (2017). Using electronic health records and nursing assessment to redesign clinical
early recognition systems. Health Systems, 112-121.

The Office of the National Coordinator for Health Information Technology. (2018, March 8). What is HIE?
Retrieved from HealthIT.gov: https://www.healthit.gov/topic/health-it-and-health-
information- exchange-basics/what-hie

The Office of the National Coordinator for Health Information Technology. (2018, March 8). Improved
Diagnostics and Patient Outcomes. Retrieved from HealthIT.gov:
https://www.healthit.gov/topic/health-it-basics/improved-diagnostics-patient-outcomes

The Office of the National Coordinator for Health Information Technology. (2018, March 8). Medical
Practice Efficiencies and Cost Savings. Retrieved from HealthIT.gov:
https://www.healthit.gov/topic/health-it-basics/medical-practice-efficiencies-cost-savings

Copyright © 2017 by University of Phoenix. All rights reserved.