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Application of electronic medical records
Paper medical records vs electronic records
Application of electronic medical records
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Health records are classified into two different purposes: The Primary purposes and Secondary purposes. Based on research, primary purpose of health records is associated directly with the provision of patient care services. It’s often classified into the following categories: Patient care delivery, patient care management, financial and other administrative processes. Each category serves an important role in the proper function of day to day in patient care. A role that patient care play is it deals with documentation of the care provided by physicians, nurses and allied health professionals. Whereas management of patient care deals with the management side of health records. Its more common to see a list of the patient procedures that are …show more content…
In many cases, all three serve the same purpose which is to provide as much detail information as possible about the patience care. For example, paper based records are also available in paper media. It is Common that the labs and test are created electronically but later printed out upon request. The electronic record is known as a digital copy of the patient health files and information. That in which are held to the standards and can be viewed by authorized staff and doctors from more than one healthcare provider. The last type of health record is the Hybrid record. The Hybrid record is a combination of paper based records and electronics records. With this type of record, it happens to be very organized in its filing information. In the Hybrid health record only the labs results, and certain test results are stored electronic. And notes from the nurse, and updates on the patience are filed paper …show more content…
An advantage of using paper records is its free. To use paper health records all, the materials that is needed is to create a paperwork packet, which is some paper and a few file folders and a cabinet to lock and organize all the files. Just by using this method yes it does save a lot of money but the time frame that they physically stored is a very timely manner which is often looked upon a disadvantage. But the biggest disadvantage of paper health records is accepting reality that at any moment they could be destroyed due to natural causes or stolen leading to a lot of valuable information lost and no way of getting it back. the hybrid method is a bit different from the other two. The advantages of a doctor’s office using it is very beneficial. According to the Concierge Medicine Today article, physicians who operate in a “hybrid” concierge medicine business model typically see 6-15 patients per day. It also said that by using this method doctors can spend more than 30-minutes per visit with each of their patients allowing doctors and patients to know each other
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
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.
In order for hospitals and other health care facilities to prevent the thousands of deaths and injuries that occur every year due to medical errors; health care systems were required to implement new record keeping technology. This technology has made patient information and treatment accessible to all who needed to see it. This is especially important when a patient has more than one attending physician and their care relies on each doctor knowing what the other one has done, serving as the prime communication tool between doctors. If organizations do not centralize their technology and essentially their patient databases, the potential for duplicate work or inefficient patient care can exponentially increase. These high tech medical records can help protect physicians and hospitals alike against any lawsuits that may be filed on behalf of their patients. By correctly and thoroughly documenting all symptoms, illnesses, treatments, medication dosages, and diagnosis’ the doctor and health care providers can effectively prove what actions were taken with the patient, communicate with third party billers, and even use the gathered information for teaching purposes. Keeping a precise record of a patient’s medical treatment makes a large difference in many aspects of health care; especially when a negligence tort or claim is filed against the hospital and/or a doctor.
If a patient has a lot of problems and has been treated, then their file will have more information. Certain records also contain history of complaints and procedures, few records have photographs with a short summary of what is present. Medical records can be electronically stored, traditionally handwritten and even voice recorded. Medical records that are written on paper and kept in folders are divided into informative sections. It contains medical terminology terms that any person in the medical field can read.
Paper based health record was considered as gold standard during the early period because it was the main source of patient’s health information, was easy to use and it requires just minimal skill. The patient health records were kept by their providers attached to the bed for the easy access of the documents for patient care. The paper records can be lost during storage affecting patient care, duplication of tests making it more expensive care, doubtful as any person can make an entry without signing the paper and most often it is hard to read. So with the growth of advancement in medicine and technology, paper based health record cannot handle which led to the implementation of electronic health record (EHR), which is in digital format, accessible at any time, convenient, accurate and complete information, reliable, improves productivity as well as reduce health care cost of the patient. It also provides better clinical decision making thus providing better outcomes in patient health, which is the goal of the
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
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
To compare EHR with paper-based records the EHR has more pros than cons. Paper-based records require a lot of storage and requires 7 years of storage. To find records through paper-based records could require a lot of work due to records being lost in boxes packed away for several years. Some places did not have proper storage room so they stored them in different areas. It took sometimes several days to weeks to get documents from doctors. Hand written paper records have poor readability writing and documents are wrote wrong due to legible hand writing.
Health information management involves the practice of maintaining and taking care of health records in hospitals, health insurance companies and other health institutions, by the use of electronic means (McWay 176). Storage of medical information is carried out by health information management and HIT professionals using information systems that suit the needs of these institutions. This paper answers four major questions concerning health information systems.
...will benefit the patient as well as the treating organization of care. The patients benefit with the confidence, comfort and security of competent, continuous care. The treating organization will benefit by not having to worry about missing information to the puzzle of person and their healthcare. Therefore the choice of electronic medical records versus paper medical records becomes evident: electronic medical records make health care more efficient and less expensive while improving the quality of care by making patients’ medical history easily accessible to all who treat them. Electronic medical records ensures patients that they are receiving competent care while establishing and maintaining optimal health and best possible quality of life, living with a medical condition, illness and/or diagnosis, with everyone involved informed of any and all changes in care.
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).
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.
Although the technology is kept on advancing from day to day, there are some clinics that are still using old method in handling their records. Piles of files in registry counter sometimes make the place looks messy and it takes a large space to store all the records of their patients. Sometimes, they cannot find a record due to misplace and the records might be lost. Each time they want to retrieve the records, they have to find based on the series number which sometimes the file is placed not according to the series number. This process will take more time than it should be. There are some clinics that are already implementing an electronic medical record and it gives positive impacts to their record management. Other than reduce time in retrieval the records of patients, the system also help to manage all the records efficiently. Besides that, by using this kind of system, the use of large space can be reduced. Same goes to the cost, the organization (clinic) can save more in terms of stationary and they do not have to hire many workers to manage their records.