Electronic Health Records

ABSTRACT
INTRODUCTION

In a typical healthcare setting, handwritten health records are still used for documenting the health status of the patient. Health record is the collection of clinical information pertaining to the patient’s physical and mental health. The healthcare team attending the patient is the one responsible in maintaining it and ensures its confidentiality. Most of the times the longer the patient stays in the hospital, the thicker the pile of his/her health records. It becomes harder each day to keep track of the previous chartings. However, there has been a development in maintaining and storing the health records, electronically. Nowadays, that the technology is becoming so advanced, instead of having handwritten health records

Thus in developing the electronic health records system, the advantages of having it outweighs the disadvantages that can be obtained while using it. Based from different evidenced based journals, there are 4 identified advantages of electronic health records and these are: better clinic information and accessibility, patient safety, better patient care, and efficiency and

Due to a lot of patient’s chart to accomplish, most of the times, physician’s handwriting could be very hard to decipher. Medical errors can result due to misread handwritten orders of the physician. The challenge of reading handwritten notes, orders, and prescriptions has been eliminated with the EHR. In EHR, patients’ chart information is now typewritten, clear, and legible. Reports and letters to other specialists and patients are comprehensive, professional, and easy to create. Chart information is always accessible and found in the same place. Paper charts, on the other hand, can become cluttered with a lot of necessary but misplaced information. Instances such as misplaced patient’s lab results can be avoided in EHR. EHRs provide routine information and reminders for the health-care provider. Missed schedules of laboratory exams can already be avoided. Health maintenance screenings can be tracked automatically by patient age, gender, past diagnoses, past medical procedures, or even family medical history, which enables the provider to be proactive in patient care. The EHR can evaluate the patient information and alert the practitioner regarding tests, procedures, or screenings that are due. With automated medical analysis the health-care provider can offer more consistent patient care. Support for medical decision making is accessible to the health-care provider through an EHR. Decision-making support gives information about medications, tests, and care