Differences Among Source Oriented Records, Problem Oriented Records, and Integrated Records.

A clinical assessment is then conducted for treatment needs. Different treatment plans are made for each client. Individualized treatment plans are used to make referrals and they are updated periodically.”

provides the students with a diagnosis to begin the care plan. Students are to use their critical

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

“a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1)

Various accreditation, professional and regulatory organizations involved in paper health records and EHRs are compared and contrasted below:

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

Unfortunately, with five medication aides and two managers all doing filing, records often get misplaced, whether they are put in the wrong section of the expand-a-file, filed under the wrong section of a resident’s binder or accidently get deposited into the secure shredding container. The implementation of a new health documentation system would be a marked improvement to the current system.

Medical records are not electronic, but paper, which causes them to become lost or misfiled. Physicians need readily access to patient records so they can treat patients effectively.

According to Rosenbaum et al. (2015), healthcare documentation combined with clinical communication that is coded for hospitalized patients is an important part of medical care. The paper or electronic healthcare record is then submitted to third party payers that provide reimbursement for services based on the guidelines of the Centers for Medicare and Medicaid Services (CMS), Medicare Severity Diagnosis Related Group (MS-DRG), and inpatient prospective payment system (IPPS) (Rosenbaum et al., 2015). The

Record retention may take form of paper documents, microfilm and x-ray imaging, and must be maintained in a way information is accessible for clinical reference upon request.

This section is to identify three client health problems the patient has and sort by prioritization.

3.2 Explain the importance of recording relevant and accurate information and using records to plan for future resource requirements.................................................................................................24

The purpose of this essay was to compare and contrast both an essay and problem question, inform the reader of what techniques are required to answer an essay and problem question, the difference between a problem and essay question and also the different approaches to each question. Having done an in-depth research, I have discovered the differences between approaches to an essay question and a problem question. Essay questions and problem questions both have similarities and differences. In answering a problem question the IRAC technique is used, however there is use special way in which to answer an essay question. Both question require in-depth research of the given topic so that the writer can have a clearer understanding of the given topics. These question both have a word limit how over an essay question can go over two thousand words while a problem question is usually under two thousand

Electronic medical records (EMR) software is a rapidly changing and often misunderstood technology with the potential to cause great change within the medical field. Unfortunately, many healthcare providers fail to understand the complex functions of EMRs, and they rather choose to use them as a mere alternative to paper records. EMRs, however, have many functionalities and uses that could help to improve the patient-physician relationship and the overall quality of patient care. In order for this potential to be realized, both the patient and the healthcare provider must have a deeper understanding of EMR purpose and function. In this paper will highlights the historical developments and its potential effects on the patient physician relationship in order to

6. El cliente los seres queridos y los prestadores de la atención sanitaria participan en el proceso de evaluación, cuando esté indicado.