Question

Which items may be needed to create a new patient record in an EHR program?

1) Patient information form
2) Credit card number
3) Laboratory orders
4) Manila folder
5) Physician notes

Answer 1

To create a new patient record in an EHR program, one would need a patient information form, laboratory orders, and physician notes. Credit card numbers are for billing purposes and manila folders are for physical records, thus both are not relevant for EHR systems.

Step-by-step explanation:

To create a new patient record in an EHR (Electronic Health Record) program, certain critical items may be needed. These items include:

1. Patient information form: This is the most basic document that includes the patient's personal information, medical history, allergies, and other important data.
2. Laboratory orders: If the patient has been referred for tests, lab orders would be included to ensure that the results are linked to the patient’s record for a comprehensive view of their health.
3. Physician notes: Notes made by the physician during consultations or assessments are crucial for ongoing treatment and care planning.

Other items like credit card numbers are generally associated with billing and not directly included in medical records. A manila folder is a physical storage tool, which is irrelevant in digital EHR systems. For maintaining an accurate and comprehensive EHR, the focus should remain on clinical and medical documentation related to the patient's care and treatment.