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There are quite a number of data sets, which are core to the physician practice HER. HER stands for Electronic Health Record, has a system that allows the capture of particular sets of information, which are critical in the physician's practice. Use of EHR and its components of alerts, reminders and clinical decision support system have been instrumental in improved quality of patient care and safety. This is due to the reduction in medical errors, improved documentation and speed of communication between healthcare providers. The data sets considered unique to physicians practice are demographic and administrative information,
One of the core data sets is the Demographic and Administrative Information. This information helps the healthcare giver in determining the identity of the patient and their insurance status. Among other things, this information adds to the EHR documentation the patient's name, address, phone number, DOB, age, sex, race and ethnicity, parent(s) name, emergency contact and the insurance information.
The second in the list of core data is the vital signs. Vital Signs help the physician determine the basic health condition, or the signs of life in the patient. The data sets used to determine the vital signs include: weight, height, BMI, head circumference, plot on growth chart, temperature, pulse, respirations, BP (blood pressure), LMP (Last Menstrual Period).
Thirdly, the patient needs to explain their Reason for Visit, also known as Chief Complaint. This information is critical to the EHR system. The other core data for the physician is EHR History of Present Illness, HPI. The details of this statistic include clinical episode, questions for parents, age appropriate for child, questions for child, age appropriate, developmental observations, age, and appropriate dietary issues sleep issues and family concerns.
The other unique data collected by the physician for the EHR documentation is Past Medical History. For this information, medications, allergies, recent injuries or illness, special healthcare needs, visits to other healthcare providers, or hospitalizations (including psychological), diagnostic test results, changes or stressors in family or home (including psychological), school issues, age appropriate, sibling names and ages, birth status, newborn history and gestational age.
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Other core data for the physicians EHR include: Physical Exam of the patient's skin, head, eyes, ears, nose and throat, mouth: teeth, mucosa, neck, lungs, heart, abdomen, back, GU (Genitourinary ), extremities, neural reflexes and even signs of abuse. Anticipatory Guidance to determine the patient's health habits, social competence, family relationships, community interaction, safety issues (e.g., car seats, bike helmets, home first-aid products, smoke detectors in home, home wiring and electrical), pets in home and guns in home. Screenings also determine the condition of the patient's vision, hearing, lead risk, hyperlipidemia risk, PPD (purified protein derivative of tuberculin test) and Fluoride in water and city water. The patient's Immunizations information is also of critical importance for the EHR to determine if they are up to date and if there were cases offside effects and refusal or objection to immunization. The Summary or Results is also of paramount importance for the HER.
It includes visit summary (include diagnosis, procedure(s), and codes), summarize other visits (include diagnosis, procedure(s), and codes), diagnostic tests ordered and results reported, prescription or treatment, medication refills, arrangements of continuing care as needed forms completion (e.g., school, camp, day care), patient instructions, handouts provided and disposition. Information regarding referral touching on issues of clinical and social referral is also important to the EHR system. Social referral analysis the issues of health insurance, social services, SSI (Supplemental Security Income), housing, WIC (Women, Infants and Children's program), food stamps, other social issues. Finally, the EHR documentation requires authentication details, which include required signatures, and title (requirements vary from state to state), clerical staff (front desk), MA (medical assistant), LPN (licensed practical nurse), RN (registered nurse), medical student, resident or fellow, and Scribe Attending.
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