Electronic Health Record And Icd 10

872 WordsDec 6, 20144 Pages
The Health Information Profession as we know it today is already in a state of expansion. There are many changes already being implemented and others that are getting ready to go into effect very soon. Two of the biggest changes are the electronic health record and ICD-10. Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary. The electronic health record came about because of a disaster that wiped out a facilities entire medical record department. The facility only had paper documents, and with the disaster
Open Document