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Healthcare informatics history and evolution
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Transcription pertaining to the field of health and medicine is the conversion of audio files into text format as dictated by a physician, and it is an important asset to medical research and documentation. This process, as it is understood today, has existed since the beginning of the 20th century with the creation of audio recording devices. Prior to this, records were messily handwritten or manually printed on a typewriter and stored in a filing cabinet. As technology has progressed, so have the different branches of the medical field, and processes have had to become more efficient out of necessity due to the growing demand for prompt service in modern society. While not every healthcare professional will need to complete medical transcription …show more content…
It is essential to have impeccable typing skills, as accuracy is key to even the easiest transcription assignments – the simplest of errors can change the meaning of a word, phrase, or sentence and alter the originally intended interpretation of the audio report. Numbers and abbreviations, in particular, must be precise and written in their correct form because of the diversity of connotations they can potentially hold based on how the dictation is written. The utilization of punctuation, capitalization, or other keyboard symbols can make the difference between a correct and incorrect analysis. Occasionally, a number will need to be spelled out instead of typed as a figure for one reason or another. This means that, along with the other factors, the form of how a number is typed must be considered as well. For example, if a sentence begins with a number, that number should be typed in a spelled-out form. Not all branches of medicine are the same; thus, different offices will implement abbreviations and numbers according to their collective requirements. It is important, as a medical professional, to familiarize yourself with these specifications to ensure that transcriptions are completed to the satisfaction of the dictating physician or other healthcare
During the 1980’s and 90’s there were many studies done that showed that medical errors were occurring in inpatient and outpatient settings at a very high rate. Computer Provider Order Entry (CPOE) systems were designed to reduce or eliminate mistakes made by using hand written orders. The CPOE system allows users to directly enter their orders into the system on computers which are then sent directly to the healthcare providers that will be implementing the orders. Previously orders were placed by writing on order sheets on patient charts. This was sometimes done by the doctor or by a nurse acting on behalf of the doctor. Order sheets were then signed by the doctor and then the information was input into the patient’s record. This left room for error due to misreading bad handwriting, confusing medications with similar names, etc.
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.
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
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
As we go through our daily routine in our jobs in any medical facilities, we are bound to make an occasional error. Misspelling a word on a chart may be one of them. If you make a mistake while you are writing in a patient's medical chart, just draw one straight line through the word and put your initials to the top right of it, and write what you meant to say next to it. Do not make any big swirly lines through the incorrect word. The chart must look as neat and professional as possible. You might try to keep track of the mistakes you make so you can be sure not to make them in the future. Common sense, I know. But this could make a huge difference in the medical profession concerning someone's life.
The use of abbreviations shortens length of many words thus really help healthcare professionals in saving time spent in writing notes. Abbreviations however do not always provide positive contributions due to misconceptions, misunderstandings, and misinterpretations leading to commitment of errors in the practice. Similarities in abbreviations for instance could root to a grave mistake. For instance the q.d. which an inscriber would like to indicate as every day could be erroneously interpreted as q.i.d. which means four times a day. Such error could result to over dosage when a certain medication is taken four times in a day instead of just once. Though some abbreviations can be easily understood clearly and exactly as to what meaning they communicate, the use of abbreviations generally invite error potentials particularly the error-prone abbreviations (ISMP, 2007) which can be best avoided by eliminating abbreviations.
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
Poor order transcriptions and documentation of orders given by doctors to nurses whether it’s verbal, written or over
Healthcare professionals associated with medical billing and coding know the progress the technology has made so far. In the last few decades, medical billing and coding has switched from being a paper-based system to a computerized format. Under HIPAA laws, medical practitioners had to develop new software in order to send out electronic bills. With the advent of electronic medical records (EMR), with one touch of a button, doctors, Nurse Practitioners and PAs can gain access to all the care a patient has ever received from every healthcare facility the patients visited previously and can figure out possible illnesses. This enables statistical documentation of the population as a whole as well. EMR can also make the healthcare system more transparent and allow integration with reimbursement data. As the healthcare system changes, this will prevent unnecessary costs and make it easier to get the reimbursements needed to treat a patient.
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
Mental health illness is often created and diagnosed from the subjective judgment of mental health professionals. Often times, diagnosis consists of undesirable traits perceived by the dominant society as a problem. Society creates beliefs and dictates social norms in order to instilling social order. Moreover, marginalized groups that are often disenfranchised are often diagnosed and labeled with mental illnesses, because of the inability to become resilient and successful from impoverished conditions. Delgado and Stefancic (2001) describe Intersectionality as multiple identities that oppress individuals that feature undesirable traits depicted in society. As a result, many people of color, features of disability and women may be diagnosed with mental health disorders due to multiple stressors in society. Hence, marginalized groups that are perceived as less desirable are likely to be diagnosed with mental health illnesses, because of their status and position in society. The mental health stigma is a form of social control, as mental health diagnosis is labeled from the dominant society’s beliefs and ideas. Furthermore, mental health diagnosis causes stigmas, and produces the inability for people to become resilient from the labels that have been created by the dominant society. Herein, many of these mental health traits are socially constructed in order to instill social control to disenfranchised groups. As a result, the placement of people in asylums and mental health diagnosis are attributed to socio-economic perspective due to social control.
...eat thing when they are used properly, but it is very important that the person using them knows when they should and should not be used. There are things that can be done to try reducing risks that are associated with the misuse of abbreviations. Although Eliminating all medical abbreviations would definitely help get rid of all the problems that follow, it does not have to be the only choice in the matter of reducing the risks. Making sure that all health care personnel follow the written policies that are in place is a very important part of working in the medical field. Accreditation agencies are now starting to compose lists of all the abbreviated terms that should not be used any more. Finally, abbreviations are an important part of any medical professional's life, but when it comes to handwritten documents it is often more of a nuisance rather then a blessing.
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,