Paperless Nursing Records

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.

The advancement in technology has rapidly transformed the world today, and the increase in the number of web-enabled devices has completely changed peoples ' lives especially the way they communicate. Electronic Health Record system, which is a digital copy of a patient’s medical history is one of the revolutionary ideas that have come with this advancement. Electronic Health Records (EHRs) are instantaneously updating records that are patient-centered designed with the aim of providing real-time information to the authorized users (Cohen, 2010). It contains all the patient’s information that is in the hand of the medical providers including their medical history, treatment dates and types, immunizations conducted to the patient and their dates, radiology images and all the laboratory results from the tests conducted in the past. All this information is held in a digital format and can only be updated by authorized users who are stationed in the medical facilities. Electronic records are designed to make it easy for different health providers and organizations to share patients’ information which streamlines their operations since all the necessary information and history can be accessed from any location at any time.

It is no secret that the medical profession deals with some of population’s most valuable records; their health information. Not so long ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method; electronic medical records or EMR’s. “The manner in which information is currently employed in healthcare is highly inefficient, which slows down communication and can, as a result, reduce the emergence and

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

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

EHR was created to have a technical way to securely exchange private and personal medical health information in hopes to improve the quality of care, decrease medical errors, limiting paper use, reduction of health care cost, and increasing a person access to affordable health care. A mandate was created for EHR stating that health records can be accessible to all facilities with patients having the capability to access their own health records at any time. Ameliorating the quality and convenience of care given to a patient, allow for cost saving measures, engage the patient and family to participate in their care, improve accuracy of medical diagnosis, and enhance the efficiency of the overall outcome of the patients’ health.

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,

Despite some barriers and challenges of EHR adoption, transitioning our office to paperless has become inevitable. Timely adoption of EHR would help our clinic receive incentives, merge paper records into the new database, and better organize patient information. In order to ensure the most seamless implementation possible, meticulous planning will be a must.

Going Paperless: Electronic Medical Records versus Paper Medical Records “Is it time to make the switch?”

Health information technology is a familiar entity for most working nurses in the year of 2017. Many nurses, have lived through the transition from paper charting to online charting. This transition has not always been a progression of ease. Change is never easy. The process of paper charting with pen and paper and the use of paper medication administration records have been the routine process for many years. With the new onset of the electronic health record (EHR) many processes have become easier, safer, and more efficient while some tasks have become more complicated, confusing, and more time consuming. The goal of this paper is to describe the electronic health record system, expand on the essence

Paper-based health records have existed since the time of Hippocrates. The most significant change in paper-based health records occurred in the 20th century with the development of electronic health records (EHRs), due to evolution of technology (Rocha & Rocha, 2014). The development of EHRs began in the mid-1960s. Since that time, EHRs have continued to advance. Many institutions are now placing a greater effort in the utilization of this advancing technology (Atherton, 2011). The main purpose of EHRs is to increase efficiency of care and organize and improve quality of data storage through new resources and applications (Rocha & Rocha, 2014). EHRs play a vital role in the healthcare system, patient care, and

The use of informatics and technology have been really helpful in eliminating the use of paper in documenting care, however; it also came with its own challenges. At the nursing facility where I work we still use paper for medication administration record (MAR) but we use point click care (PCC) for all other documentations like the nursing notes, skin assessment and SBAR. The impact that these changes has on my practice is the fact it makes charting easier as oppose to writing, it also makes the information immediately available for the health care team.

Quality, safety, and efficiency are essential attributes that healthcare workers must be able to perform to ensure their patient receives necessary care and treatment. “Implementations of potentially transformative eHealth technologies are currently underway internationally, often with significant impact on national expenditure. England has, for example, invested at least £12.8 billion in a National Programme for Information Technology (NPfIT) for the National Health Service, and the Obama administration in the United States (US) has similarly committed to a US $38 billion eHealth investment in health care. Such large-scale expenditure has been justified on the grounds that electronic health records (EHRs), picture archiving and communication systems (PACS), electronic pre-scribing (ePrescribing) and associated computerised provider (or physician) order entry systems (CPOE), and

Health information technique is biggest term in today’s era, technology used for various administrative, operations management, and direct clinical functions in health care organization. An electronic health record (EHR) is define by the Health Information Management System Society (HIMSS) as a longitudinal electronic record of patient health information generated by one or more encounter in any health care setting including patient demographics, progress

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).