Clinical Documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy and to direct care of the patient. Both Computer systems and EHRs can facilitate and improve the clinical documentation methods, which is beneficial for all patients, the care teams, and health care organizations. In this case, clinical documentation improvement has a direct impact on patients by providing quality information. However, the new technological change can also address the health care system efficiencies that differ from paper-based charting. Obviously, the implementation of clinical documentation is essential to enhance the provision of safe, ethical, and effective care.
Clinical documentation is crucial to transform the delivery of health care. Now, most hospital health care providers and data users have made a huge improvement in expanding clinical documentation use, which helps to strengthen the core relationship between every patient and their medical providers. In order to maintain patient care, this documentation must be accurate, timely, and reflect the scope of services provided. Effective
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.
In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.
Over the past few years, we have notice a significant change in the workflow of a healthcare organization. This change is caused by the technological advancements of Health Information Technology (HIT). One of the many technological advancements of HIT is the Electronic Health Record (EHR). Electronic health records are a patient’s paper chart in a digital format. It always contains real time information and can be easily accessible. With EHR put into act, it has the ability to electronically view and share a patient’s medical history, past and current medications, immunization dates, any diagnoses or allergies, as well as testing and lab reports. It is also used to document and store data, in addition with many more abilities. It is important to understand the purpose, application, challenges, and advantages of an electronic heath record. In order to get a greater understanding of its use, we will use a private family medicine practice as the foundation for implementing the EHR.
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.
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
The value of CDI clinical documentation improvement (CDI) programs are important to any facility that recognizes the requirement of complete and accurate patient documentation. Documentation is very critical because it validates the care that was given. Furthermore, it shares important data to the caregiver and improve claims processing (Leventhal,2014). The three challenges are getting physicians to buy into the program, physicians are extremely busy so they are not connecting the dots on clinical documentation, and training the physicians to get them to understand they need to do better documenting (Leventhal,2014).
The purpose of this discussion board is to describe the Electronic Health Record (EHR), the six steps of an EHR and how my facility implements them, describe “meaningful use” and how my facility status is in obtaining it, and to further discuss the EHR’s and patient confidentiality.
Electronic Health Record (EHR) is an electronic version of a patients 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 (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in
Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness
The use of technology can be seen everywhere in the world today. One area which has seen a big push to add technology is the healthcare industry. Healthcare has now progressed to the age of electronic health records (EHR). The purpose of this paper is to discuss the evolution of the EHR, including the EHR mandate and the role of the Affordable Care Act in this mandate. It will discuss the EHR plan at Hackettstown Medical Center (HMC) to include the progress HMC has made with the mandate. This paper will discuss meaningful use and HMCs status with meaningful use. Lastly, the paper will define the Health Information Portability and Accountability Act (HIPAA) and what HMC is doing to prevent HIPAA violations.
Use of EHR (electronic health records) in United States has increased in past years and have gained widespread use in the country. The use of EHR-Electronic Health Records or EMR-Electronic Medical Records and the systems that support them have gained standardized collection of health information and data for patient and healthcare providers. Because of these technologies, healthcare providers now have information about their patients at their fingertips, which has led to better and more accurate care. There are debates on using EHR. According to Mushtaq (2015), one of the most common debate is the use of EHR compliance and the value of these technologies that surround them (Mushtaq, 2015). Providers wonder if EHR use is useful and what is to be gained for the HCP-Healthcare provider. In regards to such debates and ongoing conversations, it is important to understand the definition of meaningful use and whether these technologies have resulted in meaningful use. According to Burchell (2016), The government developed the HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009, which incorporates the meaningful use program (Burchell, 2016). The program has goals that tell us how to use the meaningful use with EMR or EHR. It helps HCP and organizations alike attain, use and keep goals like patient and clinical outcomes, individual patient autonomy, and increased transparency for providers. When these goals are attained and kept it will greatly
Technology has come a long way over the years and continues to advance rapidly. The health care system is greatly affected by the advancements in technology. An example of this would be the use of electronic health records (EHR). In this paper I will be describing the electronic health record system. How my facility has initiated the EHR with following the six steps and describe meaningful use and how my facility is working towards this. Lastly I will discuss how to maintain patient confidentiality with use of EHR, and what my facility is doing to prevent HIPPA violations.
There’s no denying that EHR has advanced the quality of healthcare by improving the way information is accessed and exchanged. But despite these advancements, errors, which were simply not tolerated in paper records, are numerous in EHRs. Because of this, electronic documentation tools have been developed in an effort to increase the quality of clinical documentation, enhance communication between healthcare providers, and improve delivery of care.
An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The
When the electronic health record is coded, it can be utilized for trending, alerts (warnings or signs), health maintenance, and decision support. It can be recognized correctly and electronically distinguished by way of the computer. Document image data must have an individual to look at and understand the information. Also, codes remove uncertainties about the physician’s meaning and diagnosis. It’s very crucial and essential to document a code acknowledging the clinical data as well as to the explanation of the text. A documentation is referred to as codified when the code is saved in the patient’s electronic health record. A codified electronic health record is more beneficial because it classifies the medical provider’s results or treatments.