Health Informatics Impact

Impact of Health Informatics on the Inpatient Patient Record System

Health informatics has impacted the healthcare industry tremendously. Automatization of healthcare records is now imperative in the healthcare system to provide effective patient care. Before EHR was implemented, the care of the patient took more time, and many errors that could be avoided were identified. Since the implementation of electronic health record, the healthcare industry has seen the benefits of a more structure way of maintaining patient information, and as a consequence delivering a better patient care. I believe that the entire departments in the healthcare system have been positively impacted by health informatics. Outpatient services, same day surgery facilities,

Every provider who treat the patient will generate a progress note. The progress note will document the evolution of the patient during the inpatient stay. Changes in medication, treatment, specialty services, will be documented in the progress notes. A progress note will be generated every time any provider visit the patient during the stay, and the document will be uploaded in the electronic record. Sometimes the patient is visited by medical students, residents and fellows. In some hospitals the attending doctor or the physician in charge of the medical students must attest (sign) the progress notes done by fellows, residents and students. The attestation (signature) is done electronically and validates the information in the progress

The report of these therapies along with the therapist assessment is available in the record too. At the time of discharge the attending physician will write a discharge report that has a summary of the patient stay along with any further medical orders for the patient, like outpatient physical therapy or tests; treatment, medications, and any other service the patient would need during the patient recovery. A social worker is involved in the patient discharge, depending in the patient condition at the time of discharge, the patient can be send to another acute care facility, long term facility, nursing home, psychiatry facility, home, etc. The discharge summary and social worker reports are also added to the electronic record.

Lastly, the facility receiving the patient would also have access to the patient record. If the receiving facility is not part of the hospital where the patient was treated, the hospital will grant a special access to the electronic record; this will facilitate the continuing of care. In the other hand, if the patient is discharged home and later on he/she wish to have access to the medical record, the facility will give the patient the electronic access to the record. The patient must fill out a form when they receive the access to the record that will also become part of the medical