Electronic Health Record

1280 Words3 Pages

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 signs, medical history, immunizations, laboratory data, radiology reports and billing information (www.cms.gov). The EHR’s purpose can be understood as a complete record of patient encounters that automates access to information and has the potential to streamline the clinician's workflow in a healthcare setting. It also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting (www.cms.gov; “Electronic Health Records”, 2010). One of the main purposes of the EHR is to improve and strengthen the relationship between clinicians and their patients. It also is an attempt to reduce patient suffering due to medical errors and aid healthcare workers to make better decisions in providing quality care. The collection of data can also prevent test duplications, delays in treatments and procedures, prescription interactions, automate templates and/or forms and improve clarity... ... middle of paper ... ...p://en.wikipedia.org/wiki/Health_Level_7 Medical record privacy. (2010, August 9). Retrieved August 10, 2010 from http://epic.org/privacy/medical/ Tegan, Anne, et al. "The EHR's Impact on HIM Functions." Journal of AHIMA 76, no.5 (May 2005): 56C-H. Sprague, Lisa. (2004, September 29). Electronic health records; How close? How far to go?Retrieved August 10, 2010 from https://www.nhpf.org/library/issue-briefs/IB800_EHRs.pdf Leavitt, Mark. (2008, September 25). The Positive impacts of certification – bigger than anyone realized. Retrieved August 11, 2010 from http://ehrdecisions.com/2008/09/25/the-positive-impacts-of-certification-%E2%80%93-bigger-than-anyone-realized/ Morton, Mary. (2010). EHR acceptance factors in ambulatory care; a survey of physician perceptions. Retrieved August 11, 2010 from http://library.ahima.org/xpedio/groups/public/documents/ahima

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