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Electronic health record implementation paper
Current status of electronic health records
Importance of electronic medical records
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Electronic health records and documentation
There are three mani types of health documentation that provided patient’s medical information like EMR, EHR and personal health record; however, even when they all contain patient information they differentiate by the their accessibility. Electronic medical record refers to the patient medical record used for diagnosis and treatment but in a digital form instead of paper record. EMR is used whiten the installation or hospital providing the care for the patient. Electronic health record refers still to the patient health information but it can be access by health care providers not only within a specific clinic or hospital but also it can be access by other health care providers who are providing care for the specific patient. Personal health record makes reference to information like immunization, medical history, past diagnosis and information that can be managed by the patient itself.
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Personally, I do not think i will used it due to the fact that I believe EHR is more convenient and practical way to access health information, especially during emergency cases. On the other hand, the unique patient identifier (UPI) designed with the idea of protecting patient health information by assigning each patient with a UPI can be another great concept in the look for securing patient information for being access by unauthorized person; however, it can not be so convenient as the smart card at the time of an emergency when patient has not control of his condition and cannot provide his /her UPI. Th concept created by HIPPA to protect patient confidentiality seems reasonable and understandable but more research needs to be perform to provide the security that the community
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.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Portability can improve patient care. Patients no longer have to “tote” their cumbersome medical records around anymore. EHR’s give physicians and clinicians access to critical healthcare information in the palm of their hand, which ultimately leads to improved patient care outcomes. EHR’s also provide security to vital medical and personal healthcare information. Organizations like HIPPA defines policies, procedures and guidelines for preserving the privacy and security of discrete distinguishable health information (HHS.gov,
Electronic Health Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR as, “ an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more
An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format. It details medical problems, medications, vital signs, patient history, immunizations, laboratory data and radiology reports, progress notes .These records can be shared across different health care settings. It resides on an enterprise information systems and is exchanged via electronic networks.EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.why is it needed? It seeks to be a complete record of a patient that can follow him/her from setting to setting increasing knowledge and consistency. It allows providers to obtain a complete picture of a patient and allows firms to automate and streamline workflows. It could improve patient and financial outcomes via evidence-based decisions, quality management, data mining, tracking, and reporting.
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.
EMRs provide a common access point where clinicians and health care providers can review and document information about clients and their care. These records are essential to improving efficiency and increasing client safety (Electronic Medical Records, n.d.). Electronic reports are an enabling technology that allows medical practices to pursue more powerful quality improvement programs than is possible with paper-based records (Miller, Robert; Sim, Ida). Clinicians and clients do not have to worry about errors occurring due to the poor legibility of handwritten paper medical records. EMRs facilitate the continuity of care before, during and after hospitalization because all the data in one place. Think of the amount of time and money employees spend on phone calls, emails, and faxes ...
Comparing EHR needs across the three main settings: Creating an Electronic Health Record system that puts patient information at fingertips reducing errors, improving patient safety and lowering costs. Most importantly replacing paper records with EHR provides faster and more precise health care to the patients. Ambulatory EHR vs Inpatient HER: To manage inpatient data the new systems was designed known as inpatient EHR. Therefore, these systems are mostly used by the hospitals. From an IT point of view, inpatient data system doesn’t belong to the hospitals only but even to the group of various departments and systems.
Advances in technology have influences our society at home, work and in our health care. It all started with online banking, atm cards, and availability of children’s grades online, and buying tickets for social outings. There was nothing electronic about going the doctor’s office. Health care cost has been rising and medical errors resulting in loss of life cried for change. As technologies advanced, the process to reduce medical errors and protect important health care information was evolving. In January 2004, President Bush announced in the State of the Union address the plan to launch an electronic health record (EHR) within the next ten years (American Healthtech, 2012).
The new healthcare technology that is spreading nationwide it the EHR programs that are being implemented and updated in healthcare organizations. Government policies are in place for societies protection and privacy, it also helps to create a place where healthcare information can be utilized to its fullest potential. ONC authors’ regulations that set the standards and certification criteria EHRs must meet to assure health care professionals and hospitals that the systems they adopt are capable of performing certain functions (HealtIt, 2015).
Clinical documentation improvement for ICD-10-CM 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. Establishing accurate/measurable goals and objectives for Clinical Documentation Improvement for ICD-10-CM will ensure the quality of care and better treatment within organizations. This essay intends on demonstrating the clinical documentation
That is not to say that there is not hope for the future use of EHRs. As more and more organizations implement EHR systems, healthcare providers will have better access to patient information, allowing quicker and more precise diagnoses. Having complete patient data will help ensure the best possible care. Patients will also have access to their own information and will have the choice to share it with family members and medical personnel securely over the Internet, to better manage care for themselves and their families. And even though setting up an EHR will require an early investment of time and money it will definitely be worth it in the long run.
Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely provide better preventive care than were healthcare professionals who did not. (page 116). From 2004, EHR has initiated, even the major priority of President Obama’s agenda is EHR (Madison & Stagger, 2011). Health care administration considers EHR as the introduction of advanced technology which can improve patient satisfaction are can increase the financial incentives of the healthcare organization. Studies have pointed out that the federal policy is proposed to transform all medical records into EHR (Hebda & Calderone, 2010).
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/