Answer to Question 1
Answer: Any three of the following:
EHRs contain pertinent information relevant to a patient's condition and care. The key information includes demographics, medication, progress notes, problem lists, past medical history, lab and radiology reports, etc.
EHRs can support other activities that enhance the care process, which can include evidence-based decision support, QM, and outcomes reporting.
EHRs enhance the overall privacy and security of PHI.
Caregiver workflows are streamlined by relaying information to others involved in the provision of care, such as pharmacists, or consultants.
Answer to Question 2
Answer: Structured input uses menus with clinical terms. A series of menus are selected to create the narrative text in the documentation. The menu choices generate links to the codes, which are then created, based on the documentation. The person documenting does not have to select manually the code.
NLP also known as computational linguistics, uses artificial intelligence to extract specific information and terms from text-based documentation, analyze it, and convert it to the most likely ICD-10-CM codes. Coders utilizing a specialized application to validate the codes review the information.
Helping maintain accurate patient records is a critical part of the medical assistant's work.
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An example of an intake screen in an electronic health record.
ICD-10-CM Tabular List
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