History Of Medical Record Keeping Documents

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The history of medical record keeping documents have been traced back to Ancient Egypt around 1900BC to 1500BC. As Egyptian priests or physicians would make new discoveries about the human anatomy, they would document the findings on thick pieces of paper like fabric that was made from the vascular tissue or pith of the Cyperus papyrus plant known as papyri. During the medieval era of Europe, Physicians were known to document patient diet recommendations, successful treatment plans, and surgical procedure narrative and autopsy findings. As medical academic interests grew, professionals started publishing this collection of data as ‘observations’ or ‘casebooks’. Around the 19th century, hospital physicians started using these casebooks…show more content…
This interchange leads to locating, reporting and transparency challenges during a program and regulatory oversight audits. Donna Coomes, MBA, RHIA, CPHQ, CCS, the corporate director of medical records at Mountain States Health Alliance says, “One of the challenges was for the staff to know that it is not all in a permanent file medical record, but some of it is on the computer.” (Dimick, Chris, 2008) Hybrid systems are failing at oversight. What if anything can be done to ensure medical record documentation transparency in Multidisciplinary Health System with hybrid health records? In 2009 the federal government established The Health Information Technology for Economic and Clinical Health Act (HITECH) and supported the national implementation of certified Electronic Health Records (EHRs); funded by the Centers for Medicare and Medicaid’s (CMSs) ‘Meaningful Use’ Incentive program. “An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative, clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.” (Centers for Medicare & Medicaid Services, 2012) The purpose of the EHR is to manage and automate clinical workflows and to improve the quality of care by eliminating
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