Information Management: The Medical Record as a Legal Document

University Medical Center has recently upgraded to an electronic medical record system. The goal of this system is to create more efficient, reliable, and accessible charting and medical records for doctors, nurses, and patients. When first discussed, the staff acted favorably towards it. However, with the system now in place, the staff is having a hard time adjusting. The staff nurses believe that the charting takes time away from patient care. Charting is taking longer than it did using paper documentation. The nurses also notice that doctors’ orders are being entered wrong. They state that this is a huge issue, especially concerning medications because some staff may overlook the dosages, over-relying on the barcode scanners. Another major complaint is system downtime. The electronic medical record has only been implemented a month ago and there has already been three episodes of downtime. These issues, as well as the news of hackers accessing medical records of neighboring hospitals, have made the implementation of electronic documentation a slow process.

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

Health care providers as well as nurses must keep track of all pertinent patient information and failure to do so leads to detrimental effect on the patient's life. CIS clinical information systems are "large, computerized database management systems that support several types of activities that include physician order entry, result retrieval, documentation and decision support". CIS is intended to replace medical records department of a hospital or any other medical institution. Physicians and clinicians can safely and quickly access information, order medication and treatments and implement appropriate care. CIS will hopefully improve productivity, increase quality care and reduce costs across the organization.

Electronic Health Records (EHR) are changing the way health care is delivered to patients, not just how patient medical information is stored. In the recent past, patient-doctor visits consisted of handwritten multiple medical forms to be completed, and most times duplicated. There were several areas of concern with past patient record keeping, omission of important care information, medical interventions and prescribed medication were missed in certain cases, erroneously prescribed or duplicated and records were lost or misplaced. EHR facilities and improves the quality of care by refining access to patient record by multiple health care providers and the patient; better decision support; reporting occurs in real time and is legible which

The handwritten documentation has been the usual way of recording medical data since the nineteenth century. However, the fast development of computer technology has led to the advancement and use of electronic medical records (EMRs) throughout the past several decades (Jerant & Hill, 2000). The evolution from a paper to an electronic setting can be somewhat straightforward. The two leading reasons why most facilities chooses to convert to EMRs is patient care and safety. Health-care Information and Management Systems Society (HIMSS) presented its EMR adoption model in 2005 and now tracks the implementation growth of more than 5000 U.S hospitals (Traynor, 2011).

There are many advantages with the implementation of electronic medical records for the patient. One important advantage is the ability for the patient’s medical record to be shared amongst the patients other physicians. Information that can be shared includes recent labs, diagnostic testing, and prescribed medication. Another advantage is patients are provided access to certain medical information in his or her medical record through a patient portal. This allows patients to have a more active role in their health care. One disadvantage for patients is many feel that once electronic medical records are implemented, office visits become less personal due to the medical assistant, nurse, and/or physician is too busy answering questions on a computer or tablet.

Because of the meaning use requirements imposed by the govenrment, an electronic medical record is an integral part of all medical practices. The staff nurse discussed the safety benefits of the electronic medical records as it relates to the patient. The clinical administrator concentrated on the practice management and billing components of the computerized system as well as the quality data that can be captured.

This paper discusses the Critical Factors in Implementing an IT System in Health Facilities such as providing at least three (3) various reasons why some health care organizations have been reluctant to implement electronic medical records, discussing the essential manner in which the Health Insurance Portability and Accountability Act (HIPAA) impacts patient’s medical records, reviewing the typical workflow processes within health organizations, and decide the single most significant process that the health organization must eliminate in order to improve the service. Provide a rationale to support your response, analyzing the primary ways in which the key federal initiatives impact the standards of health care information for patient privacy, safety and confidentiality, and specifying the fundamental advantages of applying an IT system within health care organizations while predicting the new IT developments in the health care industry in the next two (2) decades.

The other terms used to describe EMR include hospital information system (HIS), computerized system (CS), and computerized physician order entry system (CPOE). This computerized setting supports the patient’s EMR across inpatient and outpatient environments and is used by health care providers to manage, monitor, and document health care delivery within a care delivery organization. The health care industry has learned from other industries that computers facilitate the speed of communication, the accuracy of information, capacity for information storage, data retrieval, and date revision. Leaders in the health care industry are developing computerized clinical record systems to manage the huge volume of

For many people in the health care field health records are an everyday part of life. Health records have many different purposes. For instance, some of the primary purposes of health records are patient care delivery, management, support, patient self-management and financial and administrative processes (Sayles, 2013). Patient care delivery is one of the most important aspects of health records. Health care professionals document the what, when, who, why, and how of patient care into health records. This information is used to determine how a patient is doing and what needs to be done to ensure the patient is taken care of. Most non-verbal healthcare professional communication is done in the health record. Health records are a place to collect

Proper patient record documentation is essential to ensuring patient care by detailing the treatments the patient received, this offers a complete picture that other health professionals can use to provide optimal medical care. This record is also used as a determinant of reimbursement to the facility. Accurate documentation is the responsibility of the nurse and is a requirement of the institution the nurse is employed at. Taking the time to complete the record accurately and thoroughly is just as important as taking care of the patient. Conversely, neglecting the patient record can prove disastrous in the form of malpractice suits and jeopardizes the hospital and risks revocation of professional licensure.

Also, a patient’s medical record is a rich source of clinical data(Gregory and Radovitzky, 2012). Therefore, they can provide the results of various test and treatments for the patient to provide an update on the patient’s progress. This allows for continuity of care for the patient as all involved

Health care systems survive due to numerous reasons, but one of their most important traits is the willingness to adapt to changes caused by the flux of the industry. Healthcare issues and healthcare delivery rarely become static due to new diseases, changing patient attitudes, medical spending, and technological innovations. The need for personnel and institutions to adjust with these issues cannot be overstated. Recently the importance of technological advances has become a forerunner in revamping medical systems. High costs, shorter hospital stays, and a reduction in hospital staff have demanded new ways information can be passed to those who need it most. Advances in information technology surround us everyday through the use of pagers,

Inevitably, health information systems (HIS) affect both patient care and documentation. Consider the following scenario. A patient with hypertension schedules routine appointments with his primary care physician. At every appointment, the nurse documents the blood pressure reading along with the most updated list of medications that the patient is currently taking. After