The Electronic Medical Records Is A Complex Entity

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 EMR is a software program used to enter patients information into a computer, which organizes and stores the information. I believe most offices will keep the paper charts in a very safe location or shred it. But I think because of the confidentiality that any and all information or records relating to patients is considered privileged. basically saying keeping all information about the patient confidential.

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.

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

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

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.

The one issue not addressed in this article is the fact that at this stage in EHRs most of those responsible for developing EHRs are people not familiar with healthcare, so they don’t quiet have the understanding of what is necessary. There is no denying how critical clinical documentation is to healthcare. According to Health Information Management Technology: An Applied Approach (pg120), “the documentation found in health records is crucial as evidence of services provided and the quality of those services.” This has become so important that many healthcare setting have initiated clinical documentation improvement programs. With a growing and ageing population in need of quality healthcare, timely and accurate clinical documentation is critical to a successful healthcare system. However, I think it is important for everyone to remember that these things take time, as stated in the article we’re still in the early days of EHRs, so as time goes on these problems are sure to get

The electronic medical record (EMR) is the replacement of paper manual charts and is being used all across the country. As per Hebda and Czar (2013), the EMR is the “building block” of the electronic health record (EHR), which can be defined as “a longitudinal record that includes client data, demographics, clinician notes, medications, diagnostic findings, and other essential healthcare information” (p.293). The widespread use of EHR’s in America is foreseeable and inevitably unavoidable, but by no means a simple and undoubtedly an effortless task to achieve.

There is opportunity to improve the quality of health care in Jones Hospital. Information technology (IT) offers the potential to address the organization’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that will aid Jones Hospital clinicians in decision-making by providing comprehensive patient information.

The electronic medical record (EMR) is a technological tool that was created for the “long term collection of medical information about patients and populations” (Gunter & Terry, 2005). EMR’s can be established, collected, managed, and referred too by authorized personnel” (Gunter & Terry, 2005). According to the Healthcare Information and Management Systems Society (HIMSS) (2015) you can use EMR’s to “collect demographics, medical history, immunizations, problems/diagnosis, medications, vital signs, laboratory data, radiology reports, progress notes and other relevant patient information/data”.

Electronic medical records (EMRs) can improve work flow, quality of patient care, and patient safety. However, according to the U.S. Department of Health and Human Services, only 4% of physicians reported to having a fully functional EMR system (2015). There are numerous barriers to implementing an EMR system: 1)They requires extensive change and training, 2) They can be expensive (The cost is usually recouped by large agencies, such as Kaiser Permanente, but costs are not recouped by smaller medical offices), and 3) There is a lack of sufficient resources for implementation and maintenance.

The purpose of the report is to discuss and decide on what EHR system would be best suited for the overall office staff, from the physician to the medical assistant, in entering pertinent information in the patient’s electronic chart. The data that needs to be collected, sorted and retrieved fall into three categories: Personal patient information, administrative and billing data, and patient demographics. Office visit medical data, Progress notes, Vital signs, Medical histories, Diagnoses, Medications, Immunization dates, and Allergies. Data from diagnostic tests, medical lab results and medical test results as well. (“What information does an electronic health record (EHR) contain? ” 2013)

There is lack of economic information related to establishing, implementing and sustaining the discharge navigation program. It was very difficult to get the project financed. Initially it was difficult to obtain top leadership support for the financing of the program.

An electronic health record (EHR) is a computer-based data warehouse of information regarding the health status of a client. It is the systematic documentation of a client’s health status and health care in a secured digital format. This form of electronic charting will replace the former paper based medical records. It is estimated that only about 2% of hospitals have a fully deployed EHR (Baker, 2012). The Institute of Medicine (IOM) has outlined eight components of an EHR that place emphasis on functions that promote patient safety. The eight components include (1) health information and data, (2) results management, (3) order entry management, (4) decision support, (5) electronic communication and connectivity, (6) patient support, (7) administrative processes, and (8) reporting (McGonigle&Mastrian 2012).

This study has been submitted to the Institutional Review Board for approval. The electronic medical record system along with data routinely collected by the interdisciplinary stroke team will be reviewed for patients that received Alteplase for the treatment of ischemic stroke. The following data will be collected: time of stroke call, time of delivery of the CT scan results to physician, time of order of Alteplase and time of Alteplase administration. All data will be recorded without patient identifiers and maintained confidentially. Descriptive statistics will be used to evaluate the average time between each event, time of stroke alert call to the time of delivery of the CT scan results to a physician, time of delivery of the CT scan results