USE OF ELECTRONIC MEDICAL RECORDS
SIGNIFICANCE OF THE CONCEPT
Advancement in health care system has made the use of electronic medical records a necessity informatics is the key to a critical decision making and a very vital aspect of nursing practice, therefore the advancement of information technology have accelerated efforts to implement a system such as the electronic medical records or Electronic Health Record (HER).
This is a collection of all individual patient’s information or data during health care delivery which are stored in electronic format and available electronically to health care professionals anywhere and at any time through Electronic Medical Records, nurses have the potentials to enhance their decision making as the patients
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With the invention of the Electronic Medical Records the traditional paper based method of recording patient’s data is faded out and the information are well organized and kept from damage, patient’s data of several years can be retrieved and analysed to provide an in-depth knowledge of the patient or client’s condition.
The health record is very important to the health care provider in order to plan an effective management program for a client the use of at a standardized Electronic Medical record as the exchange of the Patient’s health information will improve health care delivery, its quality and safety and also helps to reduce care cost by making sure that information is available to the health care provider concerned at all time. It also help to reduce and prevent medical errors and duplication of planned care and procedures are avoided.
The electronic health records ensures high quality of care, the providers can give the patients full and accurate information about their medical condition. The provider can also follow up patient’s information from previous health care facility visited by 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.
It was just yesterday when Electronic health records was just introduced in healthcare industry. People were not ready to accept it due to higher cost and consumption of time associated in training people and adopting new technology. Despite of all this criticism, use of Internet and Electronic Health records are now gaining its popularity among health care professionals, as it is the most effective way to communicate with patient and colleagues. More and more hospitals and clinics are getting rid of paper base filling system and investing in cloud base storage.
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 article addresses major aspects such as clinical trial, integrated decision support and guidance, inadequacy of paper record, and data entry. The reason that paper records are not a match for modern medicine is that they are not accessible buy multiple health professionals causing a delay in response to health care, confidentiality and security is a risk granted that anyone could physically change the record and it would become official. The author of this article predicted the basic electronic medical record features that are available today, back in 1999 and the features include integrated clinical workstations with the computational power that can assist with clinical matters, financial and administrative topics, research, and scholarly information. This report indicates that having electronic records can provide efficiency throughout the system of health care for instance the example presented in this article was the process of admission, discharge and transfer of a patient can be changed drastically due to it initially taking hours to going from in and out in minutes. This article will provide the foundation of EMR’s and how time for reform had come more than a decade ago and it’s time for reform once again. With the examples and strategic tactics provided, it is fairly simple to display the evolution of Electronic medical records from
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.
Tan & Payton (2010) describe the electronic health record (EHR), which dates back to the 1950s. These computer-based patient records have evolved into complex systems with many capabilities. They were designed to provide healthcare professionals with a comprehensive picture of a patient’s health status at any time and are meant to automate and streamline the workflow of the healthcare professional (Tan & Payton,
We can look at the patient’s allergies, their vital signs, and even their most recent weight which is important when we have a patient with Congested Heart Failure. Being able to share a patient’s medical record and all their health care encounters is so vital in the complete care of a patient. Being able to assess a patient’s medical record electronically is also important when it comes to prescribing medications because it can alert the provider to potential conflicts with other medications that the patient has been prescribed. And if a patient comes into the emergency room unconscious from an accident, the provider can still look up the patient and adjust care as needed. The electronic medical record is important in the transition of care of a patient from one provider to another. For example, when a patient is hospitalized and then discharged, they are asked to follow up with their primary care doctor within two weeks. With the provider being able to consider the patient’s electronic medical record they can see what care the patient received while they were hospitalized and vice versa, the emergency room provider is also able to consider the patient’s electronic medical record to see the care plan for the patient and the care the patient has been receiving from their primary care provider. According to HealthIT, Electronic Medical Records can reveal potential safety problems when they occur, helping providers avoid more serious consequences for patients and leading to better patient outcomes. Electronical Medical Records can help providers quickly and systematically identify and correct operational problems. In a paper-based setting, identifying such problems is much more difficult, and correcting them can take
The Electronic Health Records (EHRs) and strategic ways patients can be engaged in their health decision-making
Nowadays, the health Information Technology industry could be treated as the highly perspective branch in medicine. Many people already are using the electronic healthcare, which has significant advantages. Electronic Health Records have been imposed as the most sustainable solution toward improving outcomes (Linder, 2007). There have been serious efforts to improve the quality of health care, as the sick patients present in US receive half of the prescribed medical care and Electronic Health Records (EHR) have been verified as the most cost effective solution for improving health care (Johnston, 2007). However, a study showed that systems, which had the power of Health Information Technology, including Electronic Health Records, might increase the delivery and performance of quality care through fewer rates of medical mistakes, and clinical monitoring.
Over the last several years, electronic medical records are becoming more prominent in health care facilities, replacing traditional written records. As many electronics are becoming more prevalent with the invention of numerous smartphones and tablet devices, it seems that making medical records available electronically would be appropriate for the evolving times. Even though they have been in use to some extent for many years, the “Health Information Technology for Economic and Clinical Health section of the American Recovery and Reinvestment Act has brought paperless documentation into the spotlight” (Eisenberg, 2010, p. 8). The systems of electronic medical records mainly consist of clinical note taking, prescription and medication documentation,
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).
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/