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Introduction of personal health record
Importance of medical records
Importance of medical records
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A personal health record encompasses all of the components that are incremental to an individual’s present and future health. The elements that constitute a personal health record consist of but are not limited to: present and historical demographical, clinical, diagnostic, therapeutic and pharmaceutical data. Collectively, the assorted elements determine information about the patient (AHIMA, 2015). Personal health records do not merely aggregate pertinent facts regarding a patient’s health but also include background of the provider, insurance and legal information. Assembling a personal health record is quite different in contrast to medical records. A medical record is information gathered from a provider that is owned by the facility the medic practices at (AHIMA, 2015). With advancement of technology today, a variety of medical settings offer patient’s access to web-based portals to obtain health records from their facility. …show more content…
Together, personal health records and patient portals are equally becoming integrated in today’s society to enhance the overall quality of health. Both store information for professionals to draw conclusions and make critical decisions. In contrast, a personal health record provides maintenance of lifelong data for an individual (Fahrenholz & Russo, 2013, p. 19). An array of information is detailed including family history and founding’s extracted from the involvement of various medical professionals. Whereas, a patient portal is implemented from a specific facility and feeds information inclusive of a patient’s appointment history, lab results, and prescriptions administered. Patient portals provide accessibility for one to easily retrieve immunization records and even the ability to communicate with their provider through the
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
In its simplest form, the basic concept of a patient portal is that it is a website, that has some form of security embedded into the process, which allows identified users (patients) access to some level of their health information via the Internet. This access is controlled by authentication methods and the information is personal health data that is being hosted and/or managed by the organization (via a database). The amount or level of information that the user has accessed due is strictly set by the organization and access control through software applications that assure authentication, authorization and accountability. In a 2013 article, Gary Hamilton discuss the advantages of patient portals and state that they, “present many workflow efficiencies for providers, offer empowering tools for patient engagement and facilitate meaningful and relevant information excha...
While the patient’s personal health history is very important to provide information about their allergies, prescriptions, over-the-counter drug use, alcohol or tobacco use, and social drugs it is most effective to obtain the multi-generational health history (Lilley, Snyder, and Collins, 2016). Multi-generational
Medical patient records are organized domcuments created to obtain patient medical history and previous care. Medical records are personal documents stored by his or her health care provider. Each medical record has enough information to distinguish each patient . It contains their first and last name with gender and age.
Learning Experience Journal Entry – Director of Health Information Management and the Supervisor of Medical Records Coder
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
According to the National Alliance for Health Information Technology (2008) and the American Health Information Management Association (AHIMA) (2012), the personal health record (PHR) is defined as the individual lifelong electronic health records. Its features are electronic, readily available, personal control, standardization, resource sharing, and portability. Although the PCEHR is currently being implemented in several countries of the world, it still has many controversial disadvantages. Hoy, Yoshihashi, & Bailey, 2012) mention that some of the ideal functions of PHR, include patient controlled, longitudinal record, interoperable and resource sharing, portability, automated input of clinical reports, as well as the integration of clinician workflow. "The PCEHR is aimed to be a secure electronic summary of people's medical history stored and shared in a network of connected systems from a central electronic hub (Australian Nursing Journal, Aug. 2012; Kerai, Wood, &Martin, March 2014)”. The Australian Government has clear legal provisions on PCEHR implementation, including the conditions of participation, target participants, methods and procedures of registration, informed consent, security requirements, penalties for violation of privacy and mitigation strategies (Australian Nursing Journal, Aug. 2012; Australia Government ComLaw, 2012; Williams, 2013; Wilson, 2012). However, The Australian (2013, September 17) notes that the Australia government has invested 1 billion on the project, but only 0.6% of people actually using this program registered at about 65 million electronic health record conditions.
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.
Each time a patient visits a doctor, is admitted to a hospital, goes to a pharmacist, or sends a claim to a health plan, a record is made of the confidential health information. The use of this information is protected and pieced together by state laws, which leave gaps in the protection of patient's privacy and confidentiality. Together all of the programs mentioned are developing strategies to better protect patient records. AHIMA members foresee daily conflicts and challenges dealing with patient confidentiality and access to their records. The resolution of these issues combined will one day result in a comprehensive national standard that will enhance individual privacy, foster research and protect the public health.
Included in this paper will be my attempt to discuss the advantages and disadvantages with patients and providers communicating via patient portals. First, What is a Patient Portal? Patient Portals are healthcare related online applications that allow patients to interact and communicate with healthcare providers, such as physicians and hospitals. (Wilkipedia) The portal allows you to see, recent doctors visit, discharge summaries, Medications, Immunizations, allergies, and Lab results. Through a patient portal, Providers can also send patients post visit instructions, post clinical summaries and lab results via an attachment. This works well if you only go to one set of physicians in a group, such as a hospital portal. Many of us have probably
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.
A Summary of a Health Record Disclosure Log What is a health record disclosure log? A health record disclosure log is an accounting of shared persons protected health information (PHI). It can be an accounting of who accesses certain patient files in a medical office, so the tracking of it can tell the office manager who should not have seen those medical files.
Health information opponents has question the delivery and handling of patients electronic health records by health care organization and workers. The laws and regulations that set the framework protecting a user’s health information has become a major factor in how information is used and disclosed. The ability to share a patient document using Electronic Health Records (EHRs) is a critical component in the United States effort to show transparency and quality of healthcare records while protecting patient privacy. In 1996, under President Clinton administration, the US “Department of Health and Human Services (DHHS)” established national standards for the safeguard of certain health information. As a result, the Health Insurance Portability and Accountability Act of 1996 or (HIPAA) was established. HIPAA security standards required healthcare providers to ensure confidentiality and integrity of individual health information. This also included insurance administration and insurance portability. According to Health Information Portability and Accountability Act (HIPAA), an organization must guarantee the integrity, confidentiality, and security of sensitive patient data (Heckle & Lutters, 2011).
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.