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The importance of the electronic medical record
Introduction to electronic medical records
The importance of the electronic medical record
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Abstract— MedRec is a comprehensive record-keeping system for your personal medical information. In the present scenario, the medical history of a patient is recorded on paper and stored in various files. Over the years, these records are lost. The medical history holds immense value to both patients and doctors that is when doctor examines a patient.
Keeping track of medical records can be difficult if your health information is in multiple places or in a format (such as paper) that is difficult to use. This challenge gets harder when working with several doctors to address several health concerns. Your doctor and other health care providers maintain their own medical records about you. But many patients see advantages in also maintaining their own personal health records to record past appointments, test results, prescriptions, and more. Therefore it's the perfect replacement for unreliable paper records or various electronic systems that hold bits and pieces of your medical history. With MedRec, any and all information that is important to you is kept together in one place.
MedRec isn't just one medical record. You can keep as many records as you want. Use it for a spouse or aging parents. Use it to keep
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You recount your peanut allergy and Grandma's hypertension but forget to mention the medication you were on two years ago. Electronic health records are designed to circumvent such problems by providing an easily shareable record of all that information in one place. The potential for greater convenience and accuracy is so clear that federal law requires doctors and hospitals to start using electronic records by 2015. More than half of all U.S. doctors already do so, up from only 17 percent five years ago. Almost four in five hospitals have made the transition to electronic records. The federal government has spent more than $15 billion to help promote the
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
Your doctor(s) used to be the sole keeper of your physical and mental health information. With today's usage of electronic medical records software, information discussed in confidence with your doctor(s) will be recorded into electronic data files. The obvious concern - the potential for your records to be seen by hundreds of strangers who work in health care, the insurance industry, and a host of businesses associated with medical organizations.
The implementation of electronic health records (EHR) continues to make an impact on nursing and patient care throughout the country. As a part of the American Recovery and Reinvestment Act of 2009, all public and private healthcare providers were required to implement electronic health records in their facilities by January 1, 2014. By demonstrating “meaningful use” of the electronic medical record, facilities are able to maintain Medicaid and Medicare reimbursement levels. Providers who show that they are meeting the “meaningful use” criteria during EHR use will receive an incentive payment from Medicare and Medicaid. “Meaningful use” is “using certified technology in EHR implementation to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination; and maintain privacy and security of patient health information” (Centers for Medicare & Medicaid Services, 2013).
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
In this paper you will find that the transition from paper health records to electronic medical record is a transition that requires a lot of time and precise preparation and planning. Looking through the paper you will see that there are factors that need to be implemented. You first definitely have to have your medical records. Next you have to know the role that HIPPA will play in your transition because of regulation and violations. Then, you have to prepare for potential problems that you could possibly face. Next, you will see there are several things to evaluate from how long it will take to cost. You will see prices for workstation and the number of staff that you need to carry out your plan of action.
Medical patient records are organized domcuments created to obtain patient medical history and previous care. Medical records are personal documents stored by his or her health care provider. Each medical record has enough information to distinguish each patient . It contains their first and last name with gender and age.
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
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.
Miller, R., & Sim, I. (2004). Use of electronic medical records: Barriers and solutions. Retrieved June 29, 2011, from http://content.healthaffairs.org/content/23/2/116.short
Electronic health records is medical information recorded on computers, the data consists of a variety of data, medical history, medication, allergies, diagnoses, immunizations, labs, radiology, vital signs, billing information, and personal statistics weight and age. The EHR is designed to help with medical errors. It helps reduce errors with allergies to a medication. Also help with reading legibility and eliminate the lost forms and paperwork. It allows for the patients history to be viewed by several doctors. Doctors or nurses can update information on your record.
Jerant, A. F., & Hill, D. B. (2000). Does the use of electronic medical records improve
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
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/