The Medical And Healthcare Records

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.

Today’s world in Health care Electronic health records are being utilized in every office. With that utilization of the electronic health records from your staff and physicians and patients, the reduction in mis-diagnoses is continuing to decrease as the years pass. Some would say that EHR is a continual migration path sometimes dictated by internal organizational issues. (Latour, 2009) A CIO would need to research and evaluate every option for her hospital staff. The hospital would do great to join the newly HIR organization to extend its ability to care for patients across the continuum of care (Latour, 2005) The whole purpose of the EHR system is to provide quality care by providing care to patients ensuring accuracy, comprehensiveness, data integrity, data security, and decreased medical errors within the patients chart and clinical side.

Electronic health records (EHR) are health records that are generated by health care professionals when a patient is seen at a medical facility such as a hospital, mental health clinic, or pharmacy. The EHR contains the same information as paper based medical records like demographics, medical complaints and prescriptions. There are so many more benefits to the EHR than paper based medical records. Accuracy of diagnosis, quality and convenience of patient care, and patient participation are a few examples of the

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,

Electronic health records is a major component in the United States health care system. It has been proven to improve health care quality by saving time and reducing

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

Operational electronic health record systems (EHR) can provide the information necessary on demand, short of troublesome trial and error of probing around physical files. From the first steps of designing the system, the enquiries that will follow are predicted and accommodated. Similar to an office filing system, the appropriateness of a detailed patient record system is often adjudicated by how much time and effort are necessary to locate and recover data. Thus, an intimate cog of the design of an electronic health record system is its efficient process for access, retrieval, and reporting.

“… longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. Included in this information are patient demographics… reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, and related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”(GAO, 2010)

Paper-based health records have existed since the time of Hippocrates. The most significant change in paper-based health records occurred in the 20th century with the development of electronic health records (EHRs), due to evolution of technology (Rocha & Rocha, 2014). The development of EHRs began in the mid-1960s. Since that time, EHRs have continued to advance. Many institutions are now placing a greater effort in the utilization of this advancing technology (Atherton, 2011). The main purpose of EHRs is to increase efficiency of care and organize and improve quality of data storage through new resources and applications (Rocha & Rocha, 2014). EHRs play a vital role in the healthcare system, patient care, and

To improve healthcare in America, the Obama administration passed a law under the Health Information Technology for Economic and Clinical Health Act, to encourage the widespread use of Electronic Health Records (EHR). Under this act, Clinicians and hospital would receive incentives and reimbursement for the effective used of EHR in their practices. Electronic Health Records is an electronic version of a patient’s medical history that is maintained by the health provider over time. It includes relevant clinical data that is pertinent in improving quality of care, reducing medical errors and potential health care cost. For the purpose of this paper, two functions of EHR will be discussed: Computerized Physician Order Entry (CPOE) and Clinical Decision Support (CDS) tools. These two support tools have the potential to greatly improve quality care and to reduce health care cost.

By making health information accessible across an entire Acute Care System, Cerner EHR facilitates improved safety, care and coordination by providing clinicians with real-time health information, so that they are able to make more accurately informed decisions. Their electronic health records system eliminates the need for hand-written documentation, provides medical records clarity, improves accuracy and reduces errors. Cerner’s customizable applications were specifically designed to streamline both administrative and clinical tasks. These automated processes, ensures health care professionals are better equipped to maintain and perform all key administrative manipulations of clinical data relevant to each patient of record. Cerner EHR also

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

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 scenario selected for this evaluation project focuses on the electronic health record. The scenario involves patient documentation, clinical decision support, and performing nursing notes. The project involves evaluation and implementation of EHR. The electronic health record and clinical decision support are not only relevant to my current organization but also are particular interest of mine. The electronic health record has helped to reduce the amount of paper which was a nightmare to maintain with the number of new patients being admitted daily. The electronic health record has also reduced the amount of missed documentation and errors. Any clinician can testify to the wasted time and poor communication among providers that sometimes results because antiquated paper records still predominate in our offices and on the hospital wards (Shortliffe, E. H., Tang, P. C., & Deimer, D. E., 1991). The clinical decision support system has been a great assistance to clinicians. Nurses, health visitors and midwives, as the largest group of healthcare professionals, record and generate most of the information used to maintain and improve patient care (Levy, S., & Heyes, B., 2012). Clinical support systems (CDSS) integrate information (ideally from high-quality research studies) with the