The information record in an electronic format in the context of health has been studied and analyzed because is very important for the health care of people. The potential of clinical information safe and available in the moment of the clinical decisions are taken, in the individual context or with populations, is undeniable (10,12,15). The record format known as Electronic Medical Record (EMR) is a digital version of a paper chart in a clinician’s office. It is a repository of clinical and administrative information where are stored during all the patient`s life (14). However, the EMR involves frequently just one health facility and, sometimes, a single software for information management (19). For many health facilities at different levels of care can exchange the clinical history contained in EMR, a new concept arise: the Electronic Health Record (EHR). It is a longitudinal data repository formed from multiple events in health facilities and over time. The challenge is to standardize the format and the meaning of health data and make them available in an integrated manner throughout the life (1). …show more content…
Store clinical information in a flexible, structured and standardized is not trivial. There are a lot of types of records (concepts) involved in a clinical appointment: resulting from checks, diagnoses, prescriptions etc. And the need to register health information is growing and evolving with advances in medicine. In consequence, flexibility on the creation and adaptive reuse of concepts are requirements for health systems. This new requirements also involves structuring of data, reducing the free literal text in favor of a standard that enables recovery of information (e.g. how many procedures of type z were performed in patient y?). There is also the complex question of agreeing on standards, since many places should store information with the same structure and meaning so they can be shared among information
Generally, the development and adoption of Clinical Decision Support (CDS) systems is based on the necessity and essence of technical standards in enhancing healthcare. However, the various health IT tools must comply with some data interchange standards in order to enhance access to clinical records, lessen clinical errors and risks to patient safety, and promote innovation in “individual-based” care (Hammond, Jaffe & Kush, 2009, p.44). The need for compliance with standards is fueled by their role in enabling aggregation of informa...
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Did you ever think about how much time is spent on computers and the internet? It is estimated that the average adult will spend over five hours per day online or with digital media according to Emarketer.com. This is a significant amount; taking into consideration the internet has not always been this easily accessible. The world that we live in is slowly or quickly however you look at it: becoming technology based and it is shifting the way we live. With each day more and more people use social media, shop online, run businesses, take online classes, play games, the list is endless. The internet serves billions of people daily and it doesn’t stop there. Without technology and the internet, there would be no electronic health record. Therefore, is it important for hospitals and other institutions to adopt the electronic health record (EHR) system? Whichever happens, there are many debates about EHR’s and their purpose, and this paper is going to explain both the benefits and disadvantages of the EHR. Global users of the internet can then decide whether the EHR is beneficial or detrimental to our ever changing healthcare system and technology based living.
The case study by Elizabeth Layman (2011) is a very comprehensive compilation of the implementation of electronic health records, in relation to the Health Information Services Departments. Through this study Layman documents the conditions to be implemented to achieve satisfactory application of the change-over from the conventional pen and ledger system to computer documentation of patient’s records maintained by health networks.
Were developed to standardize descriptions of conditions, services, and items for the purpose of consistent reporting and tracking of conditions and procedures. The coding system consists of numeric and alphanumeric codes that represent a translation of the written description of conditions, services, or items provided as documented in the patient’s medical record. The coding systems required are outlined under HIPAA provisions as the standard code sets for claim submissions. Standard coding systems originally adopted under HIPAA for hospital services included ICD-9-CM, Volume I-III; HCPCS Level I CPT and HCPCS Level II Medicare National Codes; and National Drug Codes (NDC).
“With tens of thousands of patients dying every year from preventable medical errors, it is imperative that we embrace available technologies and drastically improve the way medical records are handled and processed.”
Paper based health record was considered as gold standard during the early period because it was the main source of patient’s health information, was easy to use and it requires just minimal skill. The patient health records were kept by their providers attached to the bed for the easy access of the documents for patient care. The paper records can be lost during storage affecting patient care, duplication of tests making it more expensive care, doubtful as any person can make an entry without signing the paper and most often it is hard to read. So with the growth of advancement in medicine and technology, paper based health record cannot handle which led to the implementation of electronic health record (EHR), which is in digital format, accessible at any time, convenient, accurate and complete information, reliable, improves productivity as well as reduce health care cost of the patient. It also provides better clinical decision making thus providing better outcomes in patient health, which is the goal of the
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
Health information management involves the practice of maintaining and taking care of health records in hospitals, health insurance companies and other health institutions, by the use of electronic means (McWay 176). Storage of medical information is carried out by health information management and HIT professionals using information systems that suit the needs of these institutions. This paper answers four major questions concerning health information systems.
Over the last several years, electronic medical records are becoming more prominent in health care facilities, replacing traditional written records. As many electronics are becoming more prevalent with the invention of numerous smartphones and tablet devices, it seems that making medical records available electronically would be appropriate for the evolving times. Even though they have been in use to some extent for many years, the “Health Information Technology for Economic and Clinical Health section of the American Recovery and Reinvestment Act has brought paperless documentation into the spotlight” (Eisenberg, 2010, p. 8). The systems of electronic medical records mainly consist of clinical note taking, prescription and medication documentation,
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/