Clinical Documentation and the Health Record:
The adoption of computerized records is seen as the most appropriate means of improving the quality of care while decreasing health care costs. However, the main concern is on how to design the most suitable and effective electronic health records that improves the workflow of clinicians. While clinical documentation is integral in electronic health records and accounts for a considerable portion of physicians' time, its practices have largely been dominated with legal and billing requirements. Through the effective implementation of electronic clinical documentation, it will be possible to not only lessen the rate of medication errors but it will also help in achievement of other benefits. This method of documentation has been characterized with various concerns including whether it can be leveraged to enhance the quality of care without negative impacts on the efficiency of clinicians.
Electronic Health Records can help in lessening diagnostic errors through various ways including sorting,...
Clinical Documentation Integrity: In the past few years, the healthcare system has experienced constant battle surges between internal and external customers of clinical information to transform medical data into meaningful and beneficial information. The ongoing pressure has emerged from the fact that enterprise-wide systems in the modern healthcare system need high quality data. The quality data is essential to assist in complicated business decision making on a daily basis. While it
Unlike was the case a few decades ago, health care professionals are increasingly embracing mobile devices in clinical practice. In that regard, therefore, the utility of the said devices has been growing in a wide range of functions and settings including, but not limited to, health records access and maintenance, medical training and education, patient monitoring and management, time and information management, etc. It is, therefore, recommended we continue to
Clinical Decision Support Systems: Decision support systems were first developed and implemented in the corporate world in order to support business management. In the past few years, these support systems have been integrated into health care organizations to provide a sharpened evaluation capacity to data warehousing and data mining. The refined data analysis ability can result in enhanced patient care and diagnoses through assessment of several symptoms, forecasting of some drug
S. Department of Health and Human Services, 2011). Furthermore, subpart C explains the privileges and the protections of confidentiality that is attached to the patient's record along with much exception (U.S. Department of Health and Human Services, 2011). The penalty for anyone who breaks confidentiality is imperative. In "November, 23, 2009" was increased to $11,000 (U.S. Department of Health and Human Services, 2011). This goes for anyone in the medical field
Since modern medicine can sustain patients with proper medical follow-up for years, it becomes incumbent on the profession to follow the patients and provide them with the knowledge and tracking to insure that they are observing the procedures and medications which prolong their quality of life. Given hospitals' short-term orientation with the patients, there is a need to bridge patient care before, during and after acute-care visits. While there are some
Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as part of the 2009 bailout. The focus of the act is initiating "incentives related to health care information technology…and specific incentives designed to accelerate the adoption of electronic health record systems among providers (No author, 2013). There has been a longstanding push to implement electronic health records in the U.S. health care system, for a variety of
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