Electronic Medical Records

“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)

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,

“The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care (Medical Records, 2012).” Medical information today is still being kept by using paper medical records. In 2010, 80 percent of doctors and 90 percent of hospitals were still using paper medical records. This is in the United States.

Both patients and employees often respond positively to these process improvements, as it can help keep a facility’s schedule on track. Reducing medical errors is obviously of tremendous benefit to both doctor and patient. An electronic health records system of information eliminates the problem of lost and/or misplaced patient files while also naturally eliminating data errors that can occur from transcription.

Paperless healthcare record is a longitudinal management system of keeping patients’ health information electronically 24/7 and being able to share it (Greenhalgh and Keen 2013). Paperless healthcare records continue to grow in popularity as health care organizations are implementing or soon will be implementing a system of electronic patient records on the promise that paperless healthcare records provide faster and efficient access to healthcare (Kossman and Scheidenhelm, 2008; Top et al. 2013, Boonstra et al. 2014). Electronic patient records have various forms and the term used differs between healthcare organisations. Terms such as electronic health records (EHR), electronic patient records (EPR), Health Information Technology

I am all for electronic medical records. I have been in the healthcare field long enough to remember when patients medical records were paper. In my experience, paper medical records allow for patient privacy to be compromised. Some examples on how patient privacy can be disturbed when it comes to paper medical records are that almost anyone can go into the patient 's chart that is in the nurses station. This can include physical and occupational therapists, certified nursing assistants, nurses and physicians who are not caring for the patient. There have been times where I have walked to the nurses station at my job and it

Even before electronic medical records became available, there was interest in encouraging patients to review their medical records. In doing so, researchers sought to educate, engage, and empower patients. At the same time, researchers recognized that the medical record contains technical language and raw data that was never intended for the layman, so the medical record might also worry or confuse patients. Clinical trials that gave medical patients access to their written records showed modest benefits (such as improved doctor-patient communication) with minimal risk of harm. (Ross, Moore, Earnest, Wittevrongel, & Lin 2004, page1).

Clinical documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy. Both computers and EHRs can facilitate and improve the clinical documentation methods, which is beneficial for all patients, the care teams, and health care organizations. In this case, documentation improvement has a direct impact on patients by providing quality information. However, the new technological change can also address the health care system efficiencies that result from paper-based charting. Obviously, the implementation of clinical documentation is crucial to enhance the provision of safe, ethical, and effective nursing care.

Even though paper medical records have enlivened the medical sector and brought about a quantum leap in patients’ care, they still have some shortcomings that cannot be overlooked. Consequently, health care providers continuously try to find a perfect replacement for paper medical records that can save time, space, and cost at the same

While many of the doctor notes are atrociously poor handwritten, others are neat, tidy and immaculate. Some of the doctor’s handwritings are so unreadable that we have to call their office for verification. It is time consuming and also may cause some misunderstanding and errors. It’s good to be digitized because it can potentially reduce medical and communication errors and misunderstandings. A major problem we sometimes encounter is the lack of document standardization to support smooth data exchange between healthcare systems. The lack of standardization complicates documentation exchange and increases labor work which eventually increases the cost of care and can potentially increase the chances of errors and inconsistency. I wish there

One reason why health care organizations have been hesitant to use electronic medical records is the cost. “It is not only the $40,000 that software vendors charge to install an electronic records system and the $10,000 to $15,000 for annual maintenance. It is the hassle factor and the often prohibitive cost of hiring staff to enter the data and to comply with new rules and regulations"(Reece, 2011). Facilities would have to hire IT people if the system goes down.If this system goes down that would impact the whole office. Electronic medical records will cost large amounts of money to buy and maintain.

Ever since the Industrial Revolution began in the 1880s, many things have changed. Horse-drawn carriages have been replaced by cars and telegraphs were replaced by landlines. Landlines are now considered obsolete and their predecessor, the cell phone, rules today. While many of these changes have happened, somethings have just stayed for centuries and that goes for medical records. Medical records have been kept since the Ancient Egyptians and not much has changed. We still have to write everything by hand, print copies of it, and file it on a shelf with thousands of others that it is so hard to tell one apart from another. Imagine this: What if you could fill everything out on a computer and find a patient’s file with a few quick strokes on the keyboard. It could change the way we interact with our patients and take it to a whole new level.

Paper to paperless medical health records is rapidly evolving as medical facilities are making the transition. Before going paperless a medical facility had a stack of paper charts that were lined up in alphabetical order. When a patient would arrive for their appointment the medical staff would search for the patient’s appointment on a paper-based planner. The medical staff would then pull the patient's chart and set the chart in a chart rack. When the patient was taken back to the exam room, the doctor, nurse, physician’s assistant, and or medical assistant would write in the chart and record the new patient health data. After the visit, the chart would be filed back in the wall of paper charts. If a patient called with a question regarding

The health record has been around for many years, and it first started with a group of individuals in the 1920’s to realize that documenting health care data provided better quality care. Healthcare providers recognized that they were able to treat patients more accurately with a documented history of the patients. It wasn’t until the 1980’s that healthcare professionals started to venture out into the computerized healthcare technology. In the 90’s technology was making gains and healthcare continued to venture forward into the modern more computerized world of healthcare informatics. One of the revolutionary feature of this era was the ability to get patients test results via computers, the only downsize was that they were only attainable through that computer alone. That type of information had no way of traveling though another computer. By the year 2000, a push to make electronic records began due to the spike of patient death and injuries due to medical errors by healthcare providers.

Healthcare is a prevailing topic of today’s conversation. People want and need better access to care. Electronic Health Reports provide access to better care because their implementation and use is considered to be of greatest importance for reducing medical errors and improving the quality of service that patients receive (Song et al. 2011). The traditional paper-based record keeping system will be a thing of the past as the US healthcare delivery system makes a shift to electronic record keeping. This transition will take place as an advantage that links local and national healthcare strategies and places a priority on efficient operational practices. Even though a benefit of