The Medical Field, No Observation Goes Without Documentation

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 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.

It is no secret that the medical profession deals with some of population’s most valuable records; their health information. Not so long ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method; electronic medical records or EMR’s. “The manner in which information is currently employed in healthcare is highly inefficient, which slows down communication and can, as a result, reduce the emergence and

The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies. The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. (Huston, 2013)

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,

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

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

In the modern world technology is everywhere and it affects everyone’s daily life. People are constantly attached to cell phones, laptops, and other electronics, which all have affected how people live their lives. Technology is also a large part of the healthcare system today. There are many electronics and technologies that are used in health care, such as electronic health record, medication bar code scanning, electronic documentation, telenursing, and there are many more forms of technology that impact nursing. One technology that stands out is the electronic health record. The electronic health record, also referred to as EHR, is an electronic version of a patient’s chart, and it contains is a list of the patient’s current medications, allergies, laboratory results, diagnoses, immunization dates, images, treatments, and medical history (“Learn EHR Basics,” 2014). The purpose of the electronic health record is to have a patient’s health care record available to health care providers nationwide, but the patient can decide who has access to their record (Edwards, Chiweda, Oyinka, McKay, & Wiles, 2011). The electronic health record is a very important technology in health care and it impacts nurses, nursing care, and has a significant impact on patient outcomes.

I still remember the days before EHR were started. I was working as a Health Unit Coordinator, and was responsible for getting the patient’s charts together and all the required forms that will be used for the patient doing there admission. The charts were broken down upon patient discharge, and sent to medical records. The charts would have to be requested again from medical records in the event that the patient was admitted again at a later date, and the physicians and nurses would have to go through the charts to review the patient’s history. Health Care has come a long way since then. In this paper there will a discussion and examination on the current use of electronic health records and its relationship to health care. All of the providers and nurses that are responsible for the patient’s care, are able to review and share information on the patient. Any nursing care information that is beyond the basic compliance data, is not often included in the data that is being stored though EHR Today, nursing care data, beyond basic compliance data, is very seldom included in this data which is being stored electronically, even though there are studies that showing that including nursing problems will improve the accuracy of healthcare cost and patient outcomes. Welton, Halloran, and Zone-Smith (2006). By

The use of technology in healthcare has greatly increased and grown, including the use of electronic health records (EHRs) and electronic medical records (EMRs). With the vast influx of data, the need for consistent gathering of patient data in an organized manner is crucial for patient care. Big data does not only consist of volume but different varieties and formats as well (i.e. diagnostic images, objective, and subjective data). The American Hospital Association conducted a survey revealing an increase of electronic health records (EHRs) doubling from 2009 to 2011 (Murdoch & Detsky, 2013). Murdoch and Detsky (2013) expressed this data is often perceived as a result of health care instead of essential to the health care process.

The use of medical jargon when discussing a health care plan with a patient is useless unless the patient has the same medical knowledge and understanding as the professional. That is why communication is such an important aspect of providing health care. For example: a nurse should communicate in lay-terms to their patient to (a) avoid the patient misunderstanding care instructions, (b) to hopefully avoid repeat admissions for the same cause, and (c) improve the health literacy and understanding for the

It is important for all healthcare professionals to understand medical terminology because this is the bulk of our job to interact with our patients and understand their medical needs. With that being said in order to fully fulfill our patients needs we must be knowledgeable about our job. Understanding terminology’s structure and construction help me to understand medical terms because by knowing what the prefixes, root, suffixes of the words mean then when we put these things all together it will be easy for us to know what that word means and how to use it in relation to the human

In today’s medical field technology plays a big role when it comes to patient care. Technology is huge when it comes to giving the patient the best type of quality care when they are in the hospital. In the old days people would just write it down on a sheet of paper and record it by hand, which caused mistakes. Now with the Electronic Health Record those mistakes are drastically declining. Statistics have shown that using the Electronic Health Record has lowered Nursing mistakes as well as improved patient care. Our society has progressed through the years and has been introduced with the Electronic Health Record which has drastically improved our health care system. The Electronic Health Record provides great communication between