Although EMR’s may be taking over the medical world, paper medical charts remain the most well recognized form for keeping medical records. There are however some things within paper charts that some medical personnel might argue make it a primitive aspect of the medical field. One argument in itself is that the abundance of paper that is utilized in paper charting doesn’t stand up to the “green” society we aspire to live in today. “Paper charting used to take so long, the papers would always get unorganized, they took up so much room in the nurses’ station and the worst was waiting for a doctor to finish with a chart so I could chart what I needed to” (Brittney Guggino LPN, 2012). Another acknowledged concern with paper medical charts is the illegible handwriting of clinicians, which is a common, longstanding problem. Being unable to read orders clearly creates an added risk when dealing with patients treatments, medications etc. Paper charts may be familiar but they come with many downfalls and it’s these downfalls which may sway a person’s decision in the opposite direction in regards to the
“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)
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?”
Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.
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.
“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” (CMS, 2011). Paper charting can no longer support the needs of our healthcare industry, and EHR is replacing it throughout healthcare settings in a rapid way. Also, once the patient is discharged from the healthcare setting, paper charts are stored in medical records and a new chard would open if the patient comes back later, allowing key information to be missed and put the patient safety in jeopardy.
I believe this trend is the future. Sooner or later everything in hospitals and private offices of doctors, dentist, chiropractors, etc., will be paperless. Every single patient file, x-rays, etc., will be on computers and hard drives will keep those files backed up so if anything was to happen to those files, they will be restored easily. Billing will be made easily and payments will be brought in faster than usual. Pre-authorizations will come in faster than the usual wait time. It will only
The balancing of patient care, education of staff on the new procedures, maintaining fiscal and operational benchmarks, and the managing of other projects such as improved imaging systems, and structural revisions/additions must be considered when implementing such a monumental transformation. Cultural changes have proved to be far more challenging than technology issues or budgetary concerns (DeVore & Figlioli, 2010). The group most likely to resist the change to electronic documentation are physicians. Listening to and addressing their concerns early in the planning stages and identifying those who can “champion” the project will increase the likelihood of a successful transition. Electronic documentation is an enormous adjustment in healthcare; it can and will no longer be business as usual. Education in change management is important for all healthcare workers and one that is not necessarily an Information Technology
The clinical documentation components, are the same in a paper based environment as in and electronic health record. However, the important features of electronic records vs. paper are the following:
Some physicians feel meaningful use is a burden on them, and that it could take time away from one’s patients. One might feel that all one does is input data into the electronic record. Physicians feel that they spend too much time clicking on buttons, and that there is so much information it is easy to get lost in the system. Some systems may show a lag due to all the individual now on the computers. It is hard for some to understand change, but meaningful use is a great benefit to healthcare.
* Avoiding utilizing both paper and electronic systems simultaneously after implementation as this tends to increase workloads for end-users. This may also cause possible threats to patient information and safety.
The process of migrating from paper-based charts to electronic records is a complicated process that requires dealing with all issues. The process has no particular route, but strategic planning and execution are necessary so that all risk issues get dealt before they happen. The article proposes changes made depending on the ambulatory care. The goals must become tactical, reasonable and measurable. The process requires a timeline that’s needed to ensure human resource and financial resources meet all the demands. An assessment of the hospital’s readiness determines the software and hardware gap, employee competencies and training, and human technology interaction.
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
Papers based systems work but are time consuming. The paperwork burden in hospitals is obvious. Unlike just about every other industry, health care still relies on an old-fashioned paper/fax/phone transaction process. These paper based systems