Electronic Health Care Documentation

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,

I learned a lot while researching for my topic electronic clinical documentation. As a nurse who has seen many changes in the medical world we live in , I braced myself for the challenges that came when I was informed our clinic would be going live with Epic in 1 year . It seemed like an eternity of classes but the extensive training and time to play in the learning playground of Epic , left me , the providers and the staff prepared for the challenge . Don’t get me wrong, we had some very frustrating days and some very extended hours but the positive aspects of the electronic medical record (EHR) soon out weighted the negative .The long extended hours documenting what we did in the first 3-4 months

The scenario selected for this evaluation project focuses on the electronic health record. The scenario involves patient documentation, clinical decision support, and performing nursing notes. The project involves evaluation and implementation of EHR. The electronic health record and clinical decision support are not only relevant to my current organization but also are particular interest of mine. The electronic health record has helped to reduce the amount of paper which was a nightmare to maintain with the number of new patients being admitted daily. The electronic health record has also reduced the amount of missed documentation and errors. Any clinician can testify to the wasted time and poor communication among providers that sometimes results because antiquated paper records still predominate in our offices and on the hospital wards (Shortliffe, E. H., Tang, P. C., & Deimer, D. E., 1991). The clinical decision support system has been a great assistance to clinicians. Nurses, health visitors and midwives, as the largest group of healthcare professionals, record and generate most of the information used to maintain and improve patient care (Levy, S., & Heyes, B., 2012). Clinical support systems (CDSS) integrate information (ideally from high-quality research studies) with the

As healthcare continues to evolve, it is necessary that care provided is documented efficiently and without error. This documentation should be readily available whenever needed. The electronic health record is a database that provides a reflection of all care provided. This database would be beneficial to healthcare professionals providing care to new and frequent patients. Assessment documentation, physician orders, progress noted, and results review will be beneficial when comparing current assessments

The article discusses a recent study by Annals of Internal Medicine that showed physicians spend 37 percent of their time on clinical documentation in their electronic health records. This was attributed to the fact that a number of people have use for clinical documentation in

A computer program that addresses the illegibility of paper is the Electronic Medical Record (EMR) Computer System, which is a system that allows physicians to add medical information into an electronic profile (Holroyd-Leduc, 2011). However, this system introduces new dilemmas: virtual disorganization and lost information (Rull, 2007). In addition, electronic document scanners try to address the mechanical destruction of paper. Though, the fate of these records is the same as desktop EMR systems (Laerum, 2013). So, how can health care be reformed to address the present medical errors? I believe the adoption of Apple iPads combines the freedom of writing on paper and the legibility of computers into a single technological solution. Implementing technology that decreases the occurrence of medical errors not only fixes the health care issue, but also sets your product as a model of success in reforming health care.

Electronic medical records (EMR) improve healthcare by handling personal information of the patient and reducing the frequent errors caused by storing personal information. There is no specific definition of EMR, it is only a collection of data in digital form to give the best care to the patient while accessing their personal health information. EMR caused great changes in the healthcare industry as electronic medical records are easily portable and accessible from anywhere at any time.

"If it is not written, it was never done" this mean that if it was not written down it could be lost and forgotten as time goes by like if it never happened. You can only prove what you did by the documentation that you do. If you don't document it, then you can't prove you did it. A proper documentation is always important in a healthcare setting. By having incorrect information or no information at all it may result in serious injury or death of a patient, that why it very important to keep track of all information of a patient, not only to protect the patients but also to stay on the right side of the law. The record is a legal document so everything that you write is memorialized permanently and what you don't write is questioned forever.

Finally, ternary care is care provided to patients by a team of specialist in a major hospital. Primary, secondary, and ternary facilities all use Electronic Health Records to track and store Electronic Medical Records. Users of Electronic Health Records were found to be used not only by health care professionals, but also by administrative staff and patients. Impact of Electronic Health Records was based on data and information quality. The study’s main interest was the impact to quality that EHR’s had on health care institutions. The study showed that there was no impact in time saving in documentation record keeping. However, the study did show that time was saved when information systems were used. For example, computerized nursing documents and physician orders improved communication between nurses and physicians which saved time in providing adequate patient care. In conclusion the focus of the study was to establish the need for Electronic Health Record adoption in primary, secondary, and ternary health care systems. However, different types of EHR systems and the needs of different health care professionals and consumers in the adoption and development of future Electronic Health Record

Faults may be very expensive relating to lack of faith in the medical care technique by individuals and even lowered fulfillment by either patients or health care professionals . As the world-wide-web is becoming simpler to gain access to , presenting new styles of interaction , patients now can take advantage of a larger variety of alternatives interacting in health-related system . Using each one of these facts and figures into consideration , we are able to summarize that there is an emergency to put into practice an electronic patient record

In an era of rapidly expanding science and technology usage, the Electronic Health Records (EHR) tools are a variety of tools used to improve quality measurement for better patient care and support ongoing quality improvement efforts. Without such technology support, it is hard to achieve for the management of the pharmaceutical care of patients.

The benefits of Electronic Medical Records (EMR) significantly outweigh the disadvantages, when it comes to the nursing care of patients in multiple settings. There have been multiple studies proving the enhancement and efficiency of nursing care in various areas, when electronic documentation is properly taught and utilized. Likewise, there is evidence supporting the reliability of the documentation, after comparing nurses’ verbal accounts of previously recorded information. When the programs used in electronic documentation are continually evaluated for completeness, accuracy, and quality, they become excellent tools for legislation. Electronic medical records present many advantages to the nursing care of a vast majority of patients, and also help uphold satisfactory legal and ethical implications of nursing documentation.

The medical record, either paper-based or electronic, is a communication tool that supports clinical decision making, coordination of services, evaluation of the quality health care, legal protection, education and regulatory processes. Health care industry is developing gradually. Developing includes the tools used by the healthcare professionals in order to provide quality health care. For example senior citizens may clearly recall when doctors would jot down notes of a form inside a folder. That used to be the patient’s medical file. Paper based medical records have many limitations. Main limitation is lack of

It is important to understand that patients are very satisfied with electronic health systems. For example, patients see a vast improvement in the speed at which they are being seen when they go their doctors’ office. Patients no longer have to wait on their physicians for hours due to the fact that their information can be readily available to their physicians when they come to see them. Moreover, all their information is transparent to their health care provider since all their data is in electronic form.

Medical records refer to data and information that pertains the medical history of patients. Medical records are an important component of health care as it ensures that monitoring of patient health is made easier. It is important to document medical records to be able to manage health and diagnosis of diseases adequately. According to the Joint Commission, there should be a standard of measure of recording medical records to facilitate easy retrieval by medical assistants. There are several approaches to maintaining medical records in a hospital. The standard methods include paperwork and electronic. All these methods are still usable, but special care should be made when an organization is shifting from paperwork to electronic records.