The Health Records Of Healthcare

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

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,

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

As the electronic health record gains acceptance, its relevance to individual patients also grows. Many hospitals and clinics have begun providing direct patient access to the clinical record. These portals are defined as consumer-facing systems tethered to electronic health records, allowing patient views of clinical or claims data in a single institutional electronic health record system or payers system (Conn and Lubell 2006). Portals provide motivated individuals with a way to electronically access sections of their records to recall salient instructions or obtain results of tests (Markle Foundation 2004). Some of the first such personal health records (PHRs0 were Columbia’s PatCIS system (Cimino et al. 1998) and Beth Israel Deaconess’s PatientSite, developed in 1999 (Weingart et al. 2006). Some of the most

Improving patient care is a process that always has room for improvements. It is important to make sure patients receive the best quality care available. "Studies suggest that high quality patient care relies on careful documentation of each patient 's medical history, health status, current medical conditions, and treatment plans" (Glandon, Smaltz, & Slovensky pg.3). To help with the process of quality care for patients HIPAA laws have been set in place. "The Administrative Simplification provisions of the Health

Electronic health records (EHRs) have the potential to transform the health care system into and organization that utilizes clinical and other health care information to assists providers in delivering higher quality care to patients (Menachemi & Collum, 2011). An electronic health record is an electronic version of patient’s medical history, which includes clinical data, demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, and radiology reports. Benefits associated with EHR are easily accessible medical records, reduction of medical errors, and fewer test duplications and delays in treatment. Electronic health records also improve accuracy and clarity (Menachemi &Collum,

Every day, there are multiple new inventions that are created. These creations range from new electronic devices, new automobiles, new surgical tactics, and even new ways of designing the structure, or framework, of academic buildings. Many professional disciplines bring into existence exciting breakthroughs and technological advances. These developments are vital for society in order to keep up with the fast-moving pace of the world. Perhaps, one of the most important successes of the past few decades has been the creation of Electronic Medical Records (EMR’s). According to the National Alliance for Health Information Technology, the formal definition of an Electronic Medical Record is as follows: “An electronic record of health-related information

Electronic Health Record has enhanced the way that medical information has been shared between doctors and hospitals and now it also includes the patients themselves. Hospitals have used a central location to store the

Traditional patient health records are primarily paper based and all documentation is handwritten. Electronic health records (EHR), as reported by Shi and Singh “are IT applications that enable the processing of any electronically stored information pertaining to individual patients for the purpose of delivering health care services” (p. 161). EHR systems replace the traditional format of medical records. All important data such as a patient’s demographics, problems and diagnostics, plan of care, progress notes medications, vital signs, and past medical history are electronically entered and accessed by

In today’s society, time is limited balancing professional and personal lives. People expect the quickest method of communication so they can get back to living their lives, without interruptions. E-mail, the Internet, and cellular phones make communication faster for people to get the information they need. Communication is crucial between consumers and medical providers. Electronic medical records are a mode of communication between consumers and providers. Electronic medical records patient records including medical history, treatments, allergies, lab work, surgeries, and physician’s notes relating to the patient stored electronically on a computer.

Health Information Technology (HIT) is continuously evolving and holds high promising standards when it comes to improving the health care quality in the U.S. and other countries. Health Information Technology (HIT) can improve in several areas such as: efficiency, cost reduction, quality and safety care delivery, immediately accessibility of data to clinicians by making computerized patient records available throughout a health care network (ahrq.gov 2006). To the point that congress in 2009 put aside billions of dollars from the stimulus package, to create incentives for meaningful use of Health Information Technology (HIT) to physicians or health organizations. Nonetheless, despite the bright future and potential benefits of HIT some conflicts still rise about its complete adaptation and success in the future. Mainly to those particular HITs, Electronic Medical Records (EMR), Personal Health Records (PHR) and Electronic Health Records (EHR).

An Electronic Health Record (EHR) is a system that collects and tracks health related information of an individual and populations in a digital format (1). It provides key clinical data associated with the individual including: demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports (2). The purpose of the EHR is to allow health care providers real time access to a patient’s records to provide the patient with the best care possible.

One of the most transcending advances that technology has allotted the healthcare field is the use of Electronic Health Records (EHR). Simply stated, EHRs are a contemporary approach to storing patient’s information by exchanging paper for technology (Colorado Technical University, 2017; HealthIT, 2017). Among the information that found in E H R’s include Administrative and billing data; Patient demographics; Progress notes; Vital signs; Medical histories; Diagnoses Medications; Immunization dates; Allergies; Radiology images; and Lab and test result (HealthIT, 2017).

The medical or healthcare record has multiple purposes. First, it is repository of documentation of the actions taken in patient management, the documentation of a patient’s progress, and therefore a mean’s to augment one’s memory and knowledge as well as to provide meaningful medical information to other practitioners should the patient transfer to a new provider or should the original provider be unavailable for some reason. The health electronic health record system that is currently in use at my facility is Cerner. Cerner retained the top spot for community hospitals of 101-250 beds for the same time period; it also came out the best for hospital systems. I will discuss the role of this system as it relates to memory, computation decision support and collaboration. Although there are some minor issues I have noticed throughout the years I find navigation through this system is secure and easy to use.

Electronic health records (EHRs) are essential to improving patient safety. An electronic health record is an electronic version of a patient’s medical history typed and stored on a computer or some electronic database. It would include general information about the person in question (e.g:age,gender,weight,height.), information about the patient with regards any current or previous medical conditions, allergies, treatments, medications, prescriptions, immunizations, x-ray/lab reports and any general doctor’s/nurse’s notes and reports on previous assessments throughout the patient’s lifetime. (Cms.gov, 2016.) Health records contain such a vast amount of information about a person and it is believed storing them in electronic