Essay Records Control

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.

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

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

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

9. What measures in terms of physical storage are taken to ensure the privacy of the medical record?

Unfortunately, with five medication aides and two managers all doing filing, records often get misplaced, whether they are put in the wrong section of the expand-a-file, filed under the wrong section of a resident’s binder or accidently get deposited into the secure shredding container. The implementation of a new health documentation system would be a marked improvement to the current system.

4.) double check you have the correct patient by having them say their name ,date of birth and possibly other basic information to prevent reveal of private health information

 Maintenance of complete and accurate medical records for each patient as described in RC.01.01.01. This standard was also identified by JACHO as top compliance issue for the industry.

responsibilities and duties in maintaining the records to meet needs of health care stakeholders. Abuse

Privacy and security to assure that individuals trust the exchange of their healthcare information into a system that protects their information as it is shared between health care entities. These security measures are being constructed on the federal and state levels to assure the safe transmission of patient’s healthcare information and that the public’s trust is established in these security

I still remember the days before EHR were started. I was working as a Health Unit Coordinator, and was responsible for getting the patient’s charts together and all the required forms that will be used for the patient doing there admission. The charts were broken down upon patient discharge, and sent to medical records. The charts would have to be requested again from medical records in the event that the patient was admitted again at a later date, and the physicians and nurses would have to go through the charts to review the patient’s history. Health Care has come a long way since then. In this paper there will a discussion and examination on the current use of electronic health records and its relationship to health care. All of the providers and nurses that are responsible for the patient’s care, are able to review and share information on the patient. Any nursing care information that is beyond the basic compliance data, is not often included in the data that is being stored though EHR Today, nursing care data, beyond basic compliance data, is very seldom included in this data which is being stored electronically, even though there are studies that showing that including nursing problems will improve the accuracy of healthcare cost and patient outcomes. Welton, Halloran, and Zone-Smith (2006). By

Progress. Over the last decade, the hospital has made a lot of progress regarding the use of HER’s. After the CPSI system was initiated, the transition from paper charts to computer charts began. Today, all charting is done electronically by all members of the healthcare team. From the dieticians to the physicians, everyone is trained and

Health information management involves the practice of maintaining and taking care of health records in hospitals, health insurance companies and other health institutions, by the use of electronic means (McWay 176). Storage of medical information is carried out by health information management and HIT professionals using information systems that suit the needs of these institutions. This paper answers four major questions concerning health information systems.

Many facilities and physician offices maintain patient records in a paper format known as a manual record. A variety of formats are used to maintain manual records, including the source oriented records (SOR),

The facility’s core processes include maintenance of an accurate master patient index. In the event of any of the aforementioned natural disasters, an electronic health record will be stored on a portable hard drive by the Human Resources manager. The electronic health record will include patient demographics, health index, and patient billing and coding information. In the event that the electronic health record cannot be retrieved due to extensive damage to auxiliary power, a paper master patient index will be kept in a fireproof and waterproof safe and the office manager will at times have access to this safe. In the event the Human Resources manager is not available to provide access to the safe, the office manager is the alternate. It is noted that both the electronic health record and the paper master patient index have limitations (Cunningham, 2010). The electronic health record is likely to generate duplicate medical record numbers, while the paper master patient index can be costly and printouts will be tedious. However, the benefits of the electronic health record is that admitting staff are familiar with the process of backup, storage and retrieval and it produces fewer, and possibly no duplicates (Cunningham 2010). On the other hand, the paper master patient index provides a mechanism to look up patient information and pull charts when