What Is Corporeal Archive

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,

Patients are taking an aggressive role in their healthcare needs. Patients desire to in touch with their medical records. Medical professionals are utilizing the Electronic Health Records to implement current data into information necessary to provide quality care for the patient. Thereby, managing patients’ current, and past histories. To understand what is occurring today, one must recognize why patients are taking an active approach to their healthcare.

Medical treatments require a great deal of paperwork. Before patients are allowed to go through treatments, a clinic must process their insurances, medical records, and surgery details. As a result, a lot of private information is gathered within the hospitals. With so much private information, it is essential for healthcare facilities to efficiently organize their paperwork. An unorganized recording system can prove disastrous to a hospital. Leaving patients’ paperwork publicly unattended and misplacing a file are both considered negligent. Misplacing patients’ information can potentially lead to information theft and invasion of privacy. An efficient way of storing information can be valuable in preventing HIPAA

Medical records are not electronic, but paper, which causes them to become lost or misfiled. Physicians need readily access to patient records so they can treat patients effectively.

Medicine has come a long way in the past few decades. Today’s doctors and nurses have some amazing tools at their disposals. The latest high tech equipment, modern pharmaceuticals and procedures but in many cases the most important tool that is needed is information. Patient information to be more precise is what is needed. Correct and up to the minute information about a patients history is a vital part of treatment. And yet for many, access to this most important vital tool still lingers in the dark ages. It can be found scattered around filing systems in different offices, highly subject to retrieval by hand and accessible only by phone or fax. There is a

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.

A lot of things have evolved when it comes to patient records in the medical field. In medical facilities the patient records use to be in paper form. There would be multiple pages of patient information, doctor notes, physical findings as well as diagnoses. These were all kept in a filing cabinet where mostly anyone could obtain the files and have the patient’s information. If the patient was at a different facility these records would then have to be mailed over which is not the most secure way to transfer a patients personal health records. It was then evolved that records should now be made electronically. This is so that security and transmission of a patients record can be more reliable.

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.

With the proliferation of small personal and business computers in the 1990s, records were moving more and more from paper based records that were in the doctor’s offices to digital records stored on hard drives on computers. Many of these computers were also becoming connected to networks and to the internet by this time also. With these new technologies being mixed in with medical records that were previously locked in file cabinets it all of a sudden became much easier for a patients information to be transmitted out of the doctor’s office. (HIPAA Privacy Rule and Public Health, 2003) Of course, this was not a bad thing today we all depend on the ability of our records to be easily transmitted when needed from all sorts of agencies and

“An Electronic Health Record (EHR) is an electronic version of a patient’s 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” (CMS, 2011). Paper charting can no longer support the needs of our healthcare industry, and EHR is replacing it throughout healthcare settings in a rapid way. Also, once the patient is discharged from the healthcare setting, paper charts are stored in medical records and a new chard would open if the patient comes back later, allowing key information to be missed and put the patient safety in jeopardy.

In the last decade of USA medical history there have been little to no change in medical errors in regards to improvement of care. Meaningful Use, Electronic Health Records and Health Information Technology are practices and programs that can be possible solutions for this issue. The goals of meaningful use include improving quality, safety, efficiency, and to reduce health disparities, improve care coordination and ensure adequate privacy and security of personal health information (Hoyt,2014). With meaningful use, there are three stages: stage one begins the process of capturing date and sharing the information. Stage two is advancing the data processing and sharing and building off of the first stage. Stage three is the examination of the outcomes. Meaningful Use is defined under the Center of Medicare and Medicaid (CMS) and is essentially an incentive program through the government to create a health system that is run electronically and provides higher quality of care through technology. Since the goal is to create safer and higher quality through HIT by providing an incentive for EP’s to further develop their use of the technology there must be a time line in place in order to know whether the Ep’s hitting the requirements. This year, 2014, is originally a major year for Meaningful Use however, with changes in the time line, the cost of HIT, and the increasing of objectives can lead to major complications in the initial timeline created.

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

Science and technology have always been joined at the hip. The evolution of health care services in the United States (U. S.) undoubtedly has been shaped at least in part by advancements in scientific research and knowledge, and technological innovation (Shi & Singh, 2012). The following exploration focuses on ways a specific scientific or technological event or innovation affected health care provision in the U. S. to date. Health care is dynamic. Science and technology continue to prove themselves as important facilitators of the change processes that occur in health care. The scientific method and nursing process are just a few examples that