Essay On Electronic Medical Record

The Purpose of the medical record? A medical record is a document that contains personal information about the patient health and treatment plan for the patient until births until death .Medical Record is multiplying purpose used one is for physician keep update medical record for all the time you visit the hospital or clinic this include examination , diagnosis, and treatment The second purpose of the medical record provides necessary data and also for statistics that can be you to keep track of the number of individuals with the same diagnosis and the third is keeping a financial record called date sheet for all your procedure and treatment plan. What is an Electronic Medical record? An electronic medical record is a digital computerized patient chart on a software this allows healthcare worker to have easy access to a patient health information for instance patient past medical history , diagnoses ,medication , immunization , laboratory result . The electronic record is used by physicians because it provides instant access to

patient information this allow doctors swiftly provide the best care for the individual base on the laboratory result and also past chronic medical condition . Electronic medical record has also allowed other physician, health Specialists, hospitals, and nursing home access to your medical record through the software. What are contents of medical records? A medical record don’t just contain health information, but also personal information about the patient. Personal information contains a patient name, address, social security, DOB, insurance, phone number, occupation, and work number. A medical record is a legible document it contains important information for instance patient pass histories, Diagnosis, laboratory report, consent, vital sign, patient registration form, hospitalization, prescriber medication, and treatment plan. Medical record also contains any corresponded with the physician and consent form for test to rule out certain disease by performing preventive health screening for instance mammogram or HIV screening.

Medical record privacy and confidentiality?

Each individual patient’s has the right to keep their health information private they also have a say in who has access a medical record and each healthcare employee must sign a confidentiality contract and failure not comply with the agreement will result in legal action. To protecting patient rights no medical information should be released without the patient consent in writing. To release any information the patient must first fill out an authorization form and the physician’s must sign the consent form to be release the information. The patient must get a specific reason why this information is being released and how this information should be given or received by the patient. The Patient Medical record is protected by Health Insurance Portability Accountability Act is the organization that regulates the privacy of patient’s health information. HIPAA was passed into law the year 1996

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Offer million American protection by diminish access to their health information and also help authorizations the disclosure of health information and also use privacy rule how information should be release. The HIPAA Privacy also regulation how a healthcare facility provider should protect individuals’ medical records and other personal health information and how successful they’re protected health information how the healthcare facility received, handled, or shared the health information.