Electronic Health Record Analysis

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

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

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

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

Electronic health records were a technological advancement in the healthcare industry in which paper patient record’s became digital. The transition from paper to digital charting allowed easier, quicker access to patient information for those who were authorized to do so. EHRs are secure and protected with username and password access only. It contains information such as patient medical history, procedures, diagnoses, medications, labs, tests, and treatments. Healthcare professionals and organizations who are authorized to access a patient’s electronic health record can do so at ease via a secure network or online database (HealthIT, 2013).

This can lead to more successful patient health outcomes. "The promise of fully realized EHRs is having a single record that includes all of a patient's health information: a record that is up to date, complete, and accurate" (Office of the National Coordinator for Health Information, n.d.)

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Nurses in bedside care spend most their time with the patient. Nurses collect and communicate data about the patient through information sources for the benefit of the other health care professionals who depend on the information to deliver care (Kelley, 2012). Nurse workflow and the quality of nursing care delivery may improve with the adoption EHR System to increase the ease and accessibility of information to provide time for nurses to analyze, synthesize, decide, and deliver patient care (Cornell, Riordan, et al., 2010).

Patient’s information is kept confidential and less likely to have a breach the HIPPA law. Having regular charting system, things can easily get lost. Pages can come out of the chart without knowing really knowing or noticing; personnel’s handwriting may not be legible, which cause confusing for other staff and billing, and the list can go on. With the electronic medical records, the need for paper would be less.

efficient than paper having a centralized chart to be more manageable with quicker access to patient's health

This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the

Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).

According to Chen, et al (2009), “a growing body of literature confirms the value of electronic health records (EHRs) in improving patient safety, improving coordination of care, enhancing documentation, and facilitating clinical decision making and adherence to evidence-based clinical guidelines” (p. 323).

Another big plus of the EHRs is that studies have shown that it has helped providers improve accuracy of diagnoses and health outcomes (Couch, 2008). For example, nurses could have reliable access to patients complete health information and have pictures which would help with whatever problem they might encounter. EHR doesn’t just keep patients medications and allergies, it also check for problems whenever a new medication is prescribed and it also alerts the nurse of potential problems (Couch, 2008). EHRs can also tell the nurse if potential safety problems occur, which helps them avoid more serious consequences for patients, which can lead to better outcomes. The EHRs can also help nurses quickly identify and correct operational problems, which compared to the paper-based setting, those kinds of problems would be more difficult to correct. It can also help