Using Medical Record Systems And How Electronically Stored Data Can Overcome Each Limitation

Electronic Health Records will include the same information as the paper record. This includes basic patient information such as demographics, medical history, medications, allergies, laboratory results, radiology images, and billing information. (2006) Each individual doctor can specialize their system and what they want it to include. They can add different components to the electronic health record that are important to them and needed in their practice. (2006)

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

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

The Inner City Clinic is experiencing problems with medication prescribing errors and seeks a resolution to this problem through use of electronic medical records and registration medication reconciliation. The Institute of Medicine reports in the work entitled "Preventing Medication Errors" that the "average hospitalized patient is subject to at least one medication per day. This is reported to confirm previous research findings that medication errors represent the "most common patient safety error." (Barnsteiner, nd, p.1) Medication reconciliation is described as follows:

To assess the quality of health care it is providing Quality healthcare depends on the availability of condition data. Poor documentation, imprecise statistics, and insufficient communication can result in errors and adverse incidents. Inaccurate data intimidate patient well-being and can lead to expand costs, inefficiencies, and poor presentation. Further, mistaken or incomplete data also discourage health information exchange and obstruct clinical research, production development, and quality initiatives. The impact of poor data on care is only increased by the implementation. A consequential electronic health record ameliorates the capability for healthcare providers to enact evidence-based comprehension management and decision making for

Furthermore, during a medical emergency, physicians, or nurses who do not have time to access a computer for terminal cases can just simply grab patient’s chart (Tsai, Jack.2008). It’s like when a time is of the essence, paper records can make a difference. In addition, with paper health record it is stored in either a big warehouse or lock cabinet and only authorized personnel can obtain the medical records.

The digital age is replacing the standard practices at a record breaking pace. With that increase, the need to digitize new medical records and convert existing records is becoming an issue at the top of most organizations “To Do List”. It is important for the organization to realize that both storage practices have the same risks: inappropriate access, record tampering, storage costs, and accessibility. In addition to that, the paper medical record needs to realize and identify the risks of chart legibility, while the

Paper charts can cause doubt when there is a lack in the signature, or when staff is unable to read related to illegible writing. Other issues can be; abbreviation and not timing and dating the entry contribute to inaccurate charting. Paper chart can lead to a lack of clarity with orders which can affect emergency care for critical patients. Paper charts limit the ability to prompt nurses to check on areas such as medication interactions and dosage contributing to poor patients’ outcomes. Paper charts of previous admission are kept in storage places, making it necessary to find these charts which can take time. This again delay patient care and could result in poor patient outcomes. Paper charts have an increase risk of improperly filed, leading to an increase threat of a lost chart. In a case of a medical emergency, this could be catastrophic for the patients. Another barrier is the inability for interdisciplinary members to view the paper chart. To view a paper chart, it will need to be scanned or emailed to the interested party, which again can delay treatment for the patient. The last point is, “over time paper charts will naturally deteriorate in storage” (Csiszar, J., & Media, D., n.d).

According Health IT Gov (2013), “An electronic health record (EHR) is a digital version of a patient’s paper chart that make information available instantly and securely to authorized users.” The EHR system that is currently used in my organization contains the medical and treatment histories of the patients. Depending on the individuals role make a difference in what all he or she will have access to on the system. This is a user friendly system that was built to go far beyond the standard clinical data that is typically kept in the patients paper chart. A purpose of the system is to

The key to providing high-quality healthcare is to have a complete depiction of a patient’s health record. Collecting comprehensive patient data is vital in forming a complete picture of a patient’s health record. It can help for improvements, and measures it for the intended use; for cognitive support to help integrate the data; to integrate evidenced-based practice guidelines and research; to build patient portfolios and for physician diagnosis; for continuing education for knowledge and treatments; to involve patients and their families into medical decision making in order to ensure accurate and consistent data; and to generate reliable information. To ensure that there are useful, reliable, and resource-efficient quality data in healthcare,

The organization should look at what was preform in the visit and should enter the missing information as soon as possible. The data quality and consistency are essential to ensure the safety of communication delivering patient health services and organization of care and reporting. Assessing the quality and consistency of the data requires data standards. The short-term practice provides professional health information with a clear understanding of data standards as a tool to enable interoperability and promote the quality of the data. Some of the problem with having poor-quality can be that by not informing or writing the right information on the patient chart on the same date of the visit it can make you responsible for what had happened

The main strength of the chart was that the clinician had very thorough and well-thought documentation. The clinician had taken radiographs on the patient, and all the correct forms were completed. Additionally, all the forms that needed to physically be in the paper chart were there and on the correct side. The EagleSoft documents and chart notes were filled out correctly, signed by the patient, and

After sorting through each patient’s documents I did find all of the required information in their charts. It took me awhile to go through all of the documentation and to me they were a little confusing. I thought that the charting on the male patient that was directly inputted was defiantly a lot easier to understand. When the information is directly inputted there is not as much information being added in and it is straight to the point. With the narrative charting it is so much more detailed and I feel like all of information gets jumbled up. Also, with narrative charting I feel like it is harder for nurses to find what you need because you spend so much more time scanning through all the information.

Many patients that are late must be made aware that they aren’t the only patients being seen and make it known that their chart will be notated for future references.

Also, a patient’s medical record is a rich source of clinical data(Gregory and Radovitzky, 2012). Therefore, they can provide the results of various test and treatments for the patient to provide an update on the patient’s progress. This allows for continuity of care for the patient as all involved