Adoption Of New Mode Of Documentation

Electronic health records (EHR) are health records that are generated by health care professionals when a patient is seen at a medical facility such as a hospital, mental health clinic, or pharmacy. The EHR contains the same information as paper based medical records like demographics, medical complaints and prescriptions. There are so many more benefits to the EHR than paper based medical records. Accuracy of diagnosis, quality and convenience of patient care, and patient participation are a few examples of the

Electronic health records is a major component in the United States health care system. It has been proven to improve health care quality by saving time and reducing

Paper-based health records have existed since the time of Hippocrates. The most significant change in paper-based health records occurred in the 20th century with the development of electronic health records (EHRs), due to evolution of technology (Rocha & Rocha, 2014). The development of EHRs began in the mid-1960s. Since that time, EHRs have continued to advance. Many institutions are now placing a greater effort in the utilization of this advancing technology (Atherton, 2011). The main purpose of EHRs is to increase efficiency of care and organize and improve quality of data storage through new resources and applications (Rocha & Rocha, 2014). EHRs play a vital role in the healthcare system, patient care, and

Remember when everything was paper based and computers never existed, what happen to those days? What happen to having to do things manual? Well technology sure has changed and had made things easier and more cost effective in some ways. In the 1980s and the 1990s, Electronic Health Records (EHR) was just being introduced in such organizations such as Intermountain Health Care-Utah, Partners Healthcare-Boston, and Wishard Memorial Hospital-Indiana were among the few to see the quality and efficiency of EHR. (Byers, 2011)

The purpose of Record keeping is to serve as evidence and to have an account of the care and treatment given to patient. It allows progress to patient’s health to be monitored and a clinical history to be developed to allow continuity of care by facilitating treatment and support.( Griffith And Tengnah. 2008). NMC (2008) sees recording as a very important tools in support effective communication. The NMC states that ‘all nurses must ensure that the Health Care Record for the patient is an accurate record of treatment, care planning and delivery’. Therefore nurses should carry out effective listening skills towards information given or received about patient care and treatment during a handover within a team and also read the entire necessary document on daily progress to be up to date with information.

Electronic Health Records (EHR) are just as the name implies, a computerized record of a patient’s current and past medical history. It is maintained by the provider over time, and includes all the key administrative clinical data pertinent to a person’s care (The Government & Health IT, 2013). EHRs can provide a medical story for healthcare providers of the patient’s life. They contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results (What is an electronic health record?, 2013). Unlike paper records, electronic records are easier to retrieved with the click of a button. In some cases, the time it takes

Introduction The Electronic Health Record (EHR) system has transform healthcare from a generally paper-based system to one that make use of clinical data and computer information to aid healthcare professionals in delivering the greatest quality of care. The Health Information Technology for Economic and Clinical Health Act (HITECH) which was signed in 2009 with the intent of developing EHR’s by providing incentives to healthcare organizations. The US healthcare systems needs EHR’s as historical electronic record of medical information of patients. This information includes past medical history, medications, immunizations, demographics, laboratory data, vital signs, and radiology reports.

Improving patient care is a process that always has room for improvements. It is important to make sure patients receive the best quality care available. "Studies suggest that high quality patient care relies on careful documentation of each patient 's medical history, health status, current medical conditions, and treatment plans" (Glandon, Smaltz, & Slovensky pg.3). To help with the process of quality care for patients HIPAA laws have been set in place. "The Administrative Simplification provisions of the Health

Electronic health records (EHRs) have the potential to transform the health care system into and organization that utilizes clinical and other health care information to assists providers in delivering higher quality care to patients (Menachemi & Collum, 2011). An electronic health record is an electronic version of patient’s medical history, which includes clinical data, demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, and radiology reports. Benefits associated with EHR are easily accessible medical records, reduction of medical errors, and fewer test duplications and delays in treatment. Electronic health records also improve accuracy and clarity (Menachemi &Collum,

Electronic medical records has been around for many years but only recently has it become more widely used. Medical records consisted of notes that were written by hand, some were typed, and test results that were then put in a file system of a paper chart. Many healthcare facilities do not even have paper records anymore according to Shi Leiyu & Singh, Douglas.(2015)

The Electronic Health Record (EHR) is a comprehensive electronic record of patient health information (PHI) eventuated by one or more encounters in any care delivery setting. This longitudinal information includes, demographics, vital signs, past medical history, progress notes, problems, medications, immunizations, radiology data and laboratory reports. The EHR organizes and automates the clinician 's workflow. The EHR has the ability to create a complete record of a clinical patient encounter - as well as complementary other care-related activities directly or indirectly via interface – encompassing evidence-based decision support, outcomes reporting and quality management("Electronic Health Records(Standards),"). Health

Computerized management systems or electronic medical records can work to increase the quality of care in several ways. One way being that because medical record data is all computerized, there is a significant improvement in the legibility and translation of the health information therefore resulting in fewer errors and miscommunications. Other benefits to an electronic medical record is that it aids in increasing accuracy, timeliness, and efficiency overall. Computerizing medical records is a safer and more convenient way to store, review, track, and analyze data on any given patient versus paper charting. It also cuts down on loss, cost and clutter. Therefore, because of all

In the health care system, documentation inhabits a crucial aspect of patient care that determines the appropriate care of patients. The reason for finish and precise patient record documentation is to encourage quality and congruity of care. It makes a method for correspondence in the middle of suppliers and in the middle of suppliers and individuals about wellbeing status, preventive wellbeing benefits, treatment, arranging, and conveyance of care []. However all too often the documentation persist to be misinterpreted and even loss of crucial data during documentation handovers necessary for patient visits. Documentation also accounts for patient’s waiting time and overall satisfaction of care []. To eliminate the problem of data loss and

The specific problem this research paper addresses is whether the establishment of state standardized documentation protocols can reduce poor documentation of care in hospitalized in-patients in acute care facility. The significance of this clinical problem is to show that state standard legal document protocols can lead to better patient outcomes and improve quality of care. Nursing documentation of care is very important in patients outcome, hospital administrators, practitioners and researchers regards recordkeeping as a crucial and valuable component resulting to compliance, continuity care, safety and quality of care. According to Okaisu, E.M., Kalikwani, F., Wanyana, G. & Coetzee, M., 2014), “to achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, continuous leadership support and legal monitoring”. Assessment in nursing care is the initial standard of nursing practice, which means, adequate assessment is very

Documentation, it is imperative in nursing. This is clear from Dion(2001)as referred to in Owen (2005), where she expresses that precise records guarantees nature of training as well as shields the nurse by giving proof of his or her professional capacity. However in an examination directed by the Maryland Nursing Workforce Commission (2007) that nurses discover documentation an exercise in futility. In this paper the essayist will examine the significance of nursing documentation in the present human services setting.