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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,...
The ability of physicians to provide accurate diagnoses is usually dependent on meticulousness in collecting patient's information from medical history and physical examination. Unlike the use of paper records, electronic health records will increase the timely accessibility of patients' information and enhance the clinician's knowledge about the patient. Secondly, these records can strengthen thoughtful examination by providing document succinct analysis to both clinicians and patients. Clinical documentation that promotes thoughtful examination should be based on efficient text-entry tools (Schiff & Bates par, 5).
Electronic health record systems can also reduce medical errors by promoting the documentation of ongoing patient history and assessment with which patients will not be required to begin a record from scratch with every new physician. In addition these systems should be developed with a better approach to managing problem lists through incorporating them into clinical…
Works Cited:
Schiff, Gordon D., and David W. Bates. "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?" The New England Journal of Medicine 362 (2010): 1066-069. NEJM.org. NEJM.org, 25 Mar. 2010. Web. 11 Feb. 2012. <http://www.nejm.org/doi/full/10.1056/NEJMp0911734>.
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
The health record, also known as the medical record, is a systematic documentation of a patient's medical history and care. While the primary purpose of health records is to record details regarding patient care and treatment to provide continuity of care among healthcare providers (Menachemi & Collum, 2011), there are several secondary purposes that extend beyond clinical care into areas such as legal documentation, billing, research, and quality management. From a
The other dimension is related but is definitely separate. Some end-users are not only uninformed on how to administer electronic health records, they may actively resist and otherwise undermine the setup and these people need to be identified or even removed if they will not play along. It cannot be denied that, when done properly, electronic health records allows for such a seamless and beautiful result. As such, people that
The relevance of electronic health records (EHRs) cannot be overstated when it comes to the enhancement of better and safer care for patients. This is more so the case given that they enable quick access to the records of patients, as well as enhance the safe and secure sharing of medical data. However, it is important to note that the efficient implementation of EHRs could be hindered by a number
However, because they make billing more efficient, the majority of large urban practice groups and hospitals have already made the switch to electronic records, according to Michael R. Costa, attorney and associate at Greenberg Traurig, LLP, in Boston, Mass. However, he adds, most of these organizations maintain warehouses where they store paper records that have been transcribed to electronic form. "There is resistance from some about going to a
Staff must be trained to use Electronic Health Records in a way that optimizes the potential benefits of the new technology, while avoiding sloppy habits that not only reduce effectiveness but are even potentially detrimental to the quality of health care (Hartzband & Groopman, 1998). There are literally hundreds of Electronic Health Records applications and products available on the market today. It is up to each organization to choose