Electronic Health Records : Improving The Accuracy And Efficiency Of Documentation

Electronic Health Records : Improving The Accuracy And Efficiency Of Documentation

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Electronic Health Records
The technology that exists for computerization in the health care delivery system is virtually unlimited and holds potential for improving the accuracy and efficiency of documentation. The need for patient safety has driven the increased usage of computerized documentation systems. Traditional paper medical record no longer meets the needs of today’s health care industry. The electronic health record is a record of patient health information generated by one or more encounters in any care delivery system. It ensures coordination of care because all primary caregivers can view a common record of a patients’ entire health care experience including outpatient, inpatient, and emergency care. As of January 1, 2014 a federal mandate required that all public and private healthcare providers’ changeover to digital record keeping.
Benefits and Risks of Electronic Health Records
The move to digital record keeping stemmed mostly from the American Recovery and Reinvestment Act of 2009, which offered incentives to healthcare providers that could demonstrate meaningful use of electronic heath records including improving safety efficiency, quality, and reducing health disparities. It also includes engaging patients and families, maintaining privacy and security and improving care coordination. Healthcare facilities that cannot demonstrate meaningful use by 2015 will suffer a 1% reduction in Medicare reimbursements, and it is possible that the penalties will increase with each passing year. The Obama administration gave $6.5 billion dollars in incentives to help standardize EHRs across the healthcare industry and many hospitals have spent far more transitioning from pen and paper to computer systems. Using an electronic...

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... brief period. Software systems have a system for backup files. If nurses inadvertently delete part of the permanent record it is necessary to type an explanation into the computer file with the date, time, and initials. Protection of printouts and the logging of the number of copies generated by each caregiver are ways to minimize duplicate records and protect the confidentiality of patient information.
The ultimate development of an electronic health record for patients will affect the entire health care community. The concerns on patient safety and quality improvement in health care are increasing. There is growing use of technology in health care, in the use of the electronic health record. As this occurs, the health care system is transforming. The federal government has become involved in EHR implementation, encouraging improved health care.

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