Electronic Medical Records Essays (Examples)

Electronic Medical Records

Electronic Medical ecords

While history counts the inventor of paper among the hundred most influential people in the history of mankind, the services of paper have proven to be doubtful during floods, earthquakes, fires and other disasters. With the invention of digital technology and computers, the man felt that possibly anything can be stored into data base in form of text, images and even voice. The electronic medical record offers the medical professionals a solution to keep the information of a patient including his family and medical history that can be shared among several different physicians. Such a system eliminates the need to regenerate paper work again and again.

The medical staff particularly and the public generally was unaware of use of computers some three decades ago. There was rarely a person in an institute who could use a PC in early 1990's. An average medical facility used to have…… [Read More]

Electronic Medical Records EMR Has Become One

Electronic Medical ecords (EM) has become one of the most famous topics in the healthcare industry in the recent years since the use of the Internet has extended into more areas. The popularity of electronic medical records has also been fueled by the recent increase in the need to lessen the costs of health care services. This record is an electronic information sharing system through the Internet for both providers and patients. Consequently, physicians can update their data, prescriptions, and research into these online systems as patients and doctors can access the information from anywhere in the world (Michael, n.d.). Electronic Medical ecords have both advantages and disadvantages though the merits are more than the demerits.

Advantages of EM:

As previously mentioned, the advantages associated with electronic medical records outweigh the disadvantages. Some of the major advantages of these systems include

Centralization of Patient Data:

EM are widely known for…… [Read More]

Electronic Medical Records the Applications

These computerized systems provide a platform where hospitals, medical laboratories, and health care institutions can manage their important data and deal with their patients in a more effective and well-organized way. The implementation of EMRs in hospitals started in the late 1980s but they became popular in the beginning of the 21st Century.

Now EMRs are found in every large hospital, health care institution, and laboratory. They use these systems for various purposes; including editing, modification, storage, and retrieval of patients' information and medical records, management of database of employees and supply chain members, and bringing efficiency in day-to-day functions. ith the rapid technological advancements in the medical field, the applications of EMRs will also increase in the health care industry. In future, they will be available with super-intelligent features and automatic functions which will enable health care institutions to operate with more safety and efficiency.

orks Cited

Iyer, Patricia;…… [Read More]

Medical Records Software Comparison Electronic Medical Records

Medical ecords Software Comparison

Electronic Medical ecords Software Comparative Analysis

There are over 75 different vendors of Electronic Medical ecords (EM) software applications currently providing solutions to healthcare facilities in the U.S. alone as of 2011 (Ulutas, Ulutas, Nabiyev, 2011). The key design criteria for EM systems is security (Neupert, Mundie, 2009), usability (James, Garrett, Krevit, 2009) and the ability to be integrated with legacy systems (Agarwal, Milch, Van Kuiken, 2009). This comparison includes AllScripts, ChartLogic and eClinicalWorks, three of the leading EM software application providers offering software suites today.

Comparative Analysis of EM Software Applications

All three applications are first compared in terms of how these companies are delivering them, whether it is through licensed software or over the Internet via the Software-as-a-Service (SaaS) model. Each of these applications also supports databases, requires an operating system, and has varying degrees of functionality and performance. All are HIPAA complaint, which…… [Read More]

Electronic Medical Records Have Developed to Become

Electronic medical records have developed to become an important component of today's health care systems because they lie at the center of computerized health information systems. Actually, the lack of electronic medical systems contributes to numerous difficulties in effective integration of modern technologies like decision support systems into regular clinical workflow. The development of electronic medical records have been fueled by the focus on multi-discipline computerized medical record, paperless, multi-provider, interoperable, and multi-specialty systems by various politicians, health professionals, researchers, and administrators. The development of such a system has been the focus of these stakeholders in the past two decades and has recently become a reality across several countries (Haupt, 2011). The development of electronic medical records emerged from their possibility to make health care safer, better, and more efficient

Electronic medical records have been developed because of the expectation of physicians to document their encounters with patients to ensure…… [Read More]

Electronic Medical Records Can They

The probability that clinicians will be faced with the hazardous business of conducting a visit without a patient record, that pharmacists, auditors, and other clinicians will be hindered by sloppy handwriting, or that clinicians will prescribe a medication that the patient is allergic to will be greatly diminished (Buppert, 2010).

There are some that think that EMs may generate new calamities. The technology is seen by some as bringing about a new set of risks in that EMs do not eliminate a significant set of risks that are there whether one uses the pen or the keyboard. Some clinicians are going to be bad typists, just as some clinicians are known to have bad penmanship. Malpractice defense may be disadvantaged by an excess of meaningless documentation that is generated by the use of templates. Insurance auditors often doubt the reality of documentation because of thoughtless use of templates. In addition,…… [Read More]

Electronic Medical Records Management and Personal Privacy

Electronic Medical ecords Management and Personal Privacy

Electronic Medical ecords Management and the Control of Personal Privacy Information

The ethics and security of Electronic Medical ecords (EM) is acting as a catalyst of continual innovation today and will accelerate development in this industry over the next two decades. The continual improvements in technology, security and personalization are also being driven by the need for healthcare providers to stay in HIPAA compliance as well (Lorenzen-huber, Boutain, Camp, Shankar, Connelly, 2011). With compliance to HIPAA requirements combined with demographic trends favoring increasing research & development (&D) in Electronic Medical ecords management, the field is expected to grow at a compound annual growth rate surpassing nearly every other healthcare-related field through 2015

The ethics of EM systems and their use by healthcare professionals, treatment personnel and the control that patients have over their use and review is now a key criterion for the…… [Read More]

Electronic Medical Records EMR's Electronic Medical Records

Electronic Medical ecords

EM's

Electronic Medical ecords

According to research literature it has been proven that technological innovation in regards to electronic patient records has improved communication the safety of patients. This has all been done without having to increase medical costs. EM's assist in reducing preventable errors, controlling medical care costs, and improving communication amongst the health care facilities and providers. Any technological innovation is geared towards solving a specific need that is affecting a health care provider or the patients. Using technology allows a health care facility to improve on its quality of care to the patients. Technology has also ensured that patient information is readily available to the necessary people. Using EM's a patient does not have to worry about their records not been available when they visit a health care facility. EM's allow health care providers to have access to all the patient records including the…… [Read More]

Electronic Medical Records First Student

Second Student

I agree that the most serious problem with electronic medical record-keeping is the cut and paste dilemma. Repetition and cutting and pasting of notes by physicians can be extremely problematic, and cause inaccuracies to be passed on from record to record. But this problem can also occur with paper records.

In terms of the financial barriers, it is important to note that any shift to safer and more effective technology comes at a cost to the physician, and this is, to some extent, one of the 'hazards' of doing business. Shifting to more sanitary procedures, using machines that are less risky in terms of disseminating radiation, and other changes in medical technology have all been expensive, yet deemed necessary because of the resultant improvements in patient health. The same is true regarding medical record-keeping. Patient health and keeping accurate records must be the priority.

However, complaints from physicians…… [Read More]

Electronic Medical Records Over the Years With

Electronic Medical ecords

Over the years, with the technological development and digitalization of almost all the processes, there have been calls for the healthcare technology to be adopted in a wider sense of it. This has been mainly on the development of the appropriate chip and other electronic storage systems that can hold the information about each American's medical information and any other relevant data like the physical address and the migration trend if the person moves from one town to another or even across the borders. This has been argued to be aimed at ensuring that the information about the individual is readily available to help in medically assisting the individual incase anything happens. Several methods of fully digitalizing this process have been suggested, the adio Frequency Identification (FID) being one of the major methods thought of.

Purpose of the project

Many healthcare facilities of late turn to this…… [Read More]

Electronic Medical Records in Healthcare

In case of referrals, the physicians are able to share information with ease allowing a more accurate diagnosis to be made and the sending of reports between the two physicians becomes easy since it is electronic. In these ways, electronic medical records systems help physicians and healthcare organization to improve the quality of care provided to patients as well as improving the relationship between the patient and the physician since the electronic medical records system allows a better organized and more efficient way of collecting and transmitting data aghupathi & Kesh, 2007()

Other advantages of electronic methods include the safety of medical records from disasters such as fires and water since the records are held electronically and it is easier to create secure backups offsite. They also enable the physician or medical organization to comply with HIPAA standards such as the ANSI 5010 which claims that all submissions and the…… [Read More]

Electronic Medical Records Documentation and the Role of the Nurse

Nursing

Electronic Medical ecords, Documentation, and the ole of the Nurse

Efficient use of time is one of the primary methods healthcare professionals use to save lives. When there is very little time available, and decisions have to be made with acute accuracy, it is of primary concern to have access to all necessary information immediately. Nurses and other healthcare professionals have long enjoyed this access due to charting procedures implemented by hospitals over a century ago (Bernd & Fine, 2011). However, the immediacy is has not been there because paper charts require some amount of access time. ecently, because of the advances in computer technology, nursing has seen a significant change in the type of charting that occurs. The same documents apply, but nurses have better access to a patients file because charts have entered the computer age. Thinking only of efficiency, electronic medical records (EM) have provided nursing…… [Read More]

Electronic Medical Records Importance

Middleville HC

The author of this report is to look at the theoretical test case and associated statistics of a medical facility known as Middleville egional Health Care. They are one of three hospitals serving a community of about 350,000 people. The statistics of Middleville have been provided as well as the details about its two competitors in the same metropolitan area. There are a couple of issues in play that the author of this report will address. First, there will be an explanation of the governing board's role in their overall strategic initiatives, the determining of its responsibility and its overall involvement in the same. Second, evidence-based management will be used to determine whether the actions chosen are yielding the results that they could or should reveal. Third, there will be an analysis of the aforementioned statistics of the three facilities in the area, including Middleville. Fourth, there will…… [Read More]

Brands of Electronic Medical Records Electronic Medical

Brands of Electronic Medical ecords:

Electronic Medical ecords (EM) are computerized medical systems that are created within a healthcare organization that allow the storage, retrieval and alteration of records. In most cases, these systems tend to be part of the local distinctive health information system within an organization that provides care like doctor's surgery or hospital. There are many brands of electronic medical records that are in existence today which are designed to eradicate many problems in the contemporary medical practice. These brands of electronic medical records include the following

NextGen EM:

NextGen Electronic Medical ecord is a resourceful, multi-module system which can be used to automate the workflow in medical practice regardless of the specialty and size of the particular practice (Corey, 2008). The system comes with pre-loaded specialty templates that contain detailed choices for documenting histories of patients, procedures and evaluations. In addition, this software contains applications that…… [Read More]

EMR Electronic Medical Records EMR

Selecting the right vendor (background check)

Choosing the right vendor can be just as important as the system being setup and the software being utilized. Choosing the right vendor is just as important as choosing the right EMR software. Daniel Ray, in the article, "Electronic Medical Records (EMR) Vendors- Points to Consider," declares the following things are essential in choosing the right vendor for your business:

1. Checking the track record: evaluate the history of the company and their reputation in relation to the services being offered and the past service to other clients.

2. Evaluate your needs: start by making a detailed list of the features and services you require from the vendor. Compare this list to any services already being utilized by the practice.

3. Consultation: before deciding on a particular vendor and software, consult other practitioners that are already using EMR software, consult the references of previous…… [Read More]

Pulse of Electronic Medical Records Taking the

Pulse of Electronic Medical ecords

Taking the Pulse

Dr. Cara is treating a patient for congestive heart failure in the hospital emergency room. The elderly female patient has made multiple trips to the E the last four months after suffering chest pains, palpitations and other health scares.

Before ending her 12-hour shift, Dr. Cara writes instructions on the patient's medical chart. Under the column that reads "medications," she writes "now nec,," an abbreviation for "now necessary."

An hour later, the next attending E physician reviews the chart -- and then, struggling for clarity, reads it several times again. Is that a "w" or a "t"? Is that word "now" or "not"? He cannot reach Dr. Cara by phone, but sees that she has been consulting with the patient's cardiologist. Assuming from this piece of information that the patient has been prescribed medication from the cardiologist, the physician reads Dr. Cara's…… [Read More]

Healthcare Reform and Electronic Medical Records an

Healthcare Reform

Reform and Electronic Medical Records

An Interview with Bernie Saunders

"Imagine a world where everything important about a patient is known to the physician the first time that patient presents," says Andrew Rubin, vice president for NYU Medical Center Clinical Affairs and Affiliates in New York City (Mann, N.d.).

hen doctors have complete and accurate record of the patient's medical health history they have the potential to reduce errors and improve patient care. There are many cases in which a patient may not be able to understand or recall many of the things that pertain to their own care. Having a comprehensive record that can be updated in real time and transferred to and from health care providers electronically could provide major improvements in the quality of care. There would be less chance that a diagnosis is missed because of missing information. "e need to be able to…… [Read More]

Disruptive Technology of Electronic Medical Records EMR

Training staff members requires additional costs. There is also the 'time' cost of using the system on a daily basis. Furthermore, many find the demands of using the system -- typing into a machine as the patient talks -- to be profoundly impersonal and contrary to the true nature of practicing medicine. Doctors and nurses want to focus on people, not on machines, and they view EM as a machine-driven intrusion into the way they practice medicine. However, supporters of electronic medical records contend that it is this desire to ignore the mundane side of medical record-keeping that often results in bad medicine. The great advantages of EM are that they do require that providers enter all relevant data and ensure that patients sign necessary request forms. And patient health as a whole will be improved if by using EM, there can be comparisons made between different patients. Data trends…… [Read More]

Electronic Medical Record EMR Ventors

records are being replaced with electronic records in all fields. This is especially important in the medical field, where stores information is useful when a patient or doctor must access it in seconds. Computerized systems, however, have not achieved the same degree of utilization in the medical field as in other business fields, for instance, either in the Western world or elsewhere.[footnoteRef:1] However, as mentioned above, these systems can be vitally important. According to some, Electronic medical record systems lie at the center of any computerized health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerized medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in many western countries.[footnoteRef:2] Thus, though there are problems, these…… [Read More]

Electronic Medical Records Interoperability

Interoperability of Electronic Medical ecords

Electronic Health ecords (EHs) are patient-management tools that have been created in the health sector to help coordinate patient care. These tools or system focuses on capturing patient-generated health information from outside the clinical setting and incorporating it into the patient's medical history. Electronic health records were developed to help improve patient care through sharing patient information seamlessly. However, for EHs to have the ability to share patient information seamlessly, an interoperable health information technology environment should be established. This essentially means that an interoperable health IT environment is mandatory for electronic health records to be effective.

What is Interoperability?

Interoperability is a term used to refer to the level with which devices and systems can share data and interpret it (Healthcare Information and Management Systems Society, 2013). This means that two devices or systems are considered interoperable when they exchange data seamlessly and eventually…… [Read More]

Ruchi Tomar Advantages of Electronic Medical Records

The issue of misplaced or lost patient files is also gotten rid of. These advantages aid in producing a marked rise in the health connected security of patients and the welfare of patients (Ayers, 2009). Furthermore, electronic medical records and patient care are identical in that such systems effortlessly permit restrictions to be placed upon end users' admission to specific information of the patient. This personal security feature is likewise significant to meeting a patient's confidentiality anxieties.

Figure 4 Electronic medical records and their advantages with patients (Slaughter, 2000).

The Benefits of access that is easy to each patient's comprehensive medical information, and the ability for physicians to rapidly take part in medical records and organize patient care. Even though every department at SMG utilizes the EM, it is particularly valuable in the Urgent Care Center when rapid admission to a patient's material can make all the change in medical…… [Read More]

Transitioning to Computers and Electronic Medical Records in Healthcare

HMS (healthcare management systems) and EMRs (electronic medical records) have been widely praised as significantly adding to patient safety and quality of care. They can permit healthcare institutions to keep more accurate databases on patients, all in one location, and can ensure that a patient’s full medical records are available, even if the patient is not responsive and the patient’s family is not available. Prior treatments, current and past medications, and patient allergies can all be easily accessed with a point and a click. But transitioning to such healthcare systems is not always without issues and often involves a significant investment of time and money.

First of all, from a staffing point of view, change management is needed to ensure that the transition is effective. One helpful way to view change of any kind within an organization is that of Lewin’s Change Management Model, which suggests that organizations must first…… [Read More]

Medical Records Case Study Section I Introduction

Medical Records Case tudy

ection I (Introduction) -- Liam O'Neill and William Klepack, the authors of Case tudy # 3, Integrating Electronic Medical Records and Disease Management at Dryden Family Medicine, begin their published findings by introducing readers to the concept of electronic medical records (EMR). The authors immediately narrow their focus to the adoption and implementation of EMR by Dryden Family Medicine, a rural family practice located in upstate New York, and explain that "for smaller group practices, electronic medical records (EMR) adoption is a huge undertaking that poses significant risks" (O'Neill and Kleback, 2010). The Introduction section then covers the multitude of obstacles encountered by small group practices attempting to convert to EMR, including the limited information technology experience possessed by most staff members, and the constant concern of budgetary constraints. Finally, the authors seek to clarify the emphasis of their study by stating that their focus remains…… [Read More]

Electronic Health Record

large number of changes in the healthcare industry, largely due to globalization and technological improvements. Much of the change has been the result of the cost of healthcare and its continual rise. For example, in 1990 the average cost of care per person was $2,800, in 2000 it was $4,700 and then in 2010 close to $8,000. One way to reduce these costs and improve efficiency is to allow healthcare professionals to spend more time with their patients rather than filling out redundant paperwork, to increase information accuracy, and to provide a way for medical professionals in Emergency Rooms or other health care facilities to have access to critical patient information. his can be accomplished through the use of Electronic Medical Record Systems, or ERM systems.

Diabetes is a group of metabolic diseases that surround the body's ability to produce and use sugars and efficiently process those sugars. Globally, there…… [Read More]

Medical Records System Definition of

The master patient index (MPI) value was mainly liked by the personnel in the medical record section.

The Golden 90s

Equipped with MPI and record-keeping growth, software designers sustained to generate and progress with a new emphasis on individual hospital sections. Auxiliary department purposes, for example radiology and laboratory showed to be fairly adaptive to software that is fresh and innovative, and computer healthcare applications start to show on the market. Patient test outcomes that instigated in the laboratory and radiology department now too were obtainable via computers nonetheless again with limit as the outcomes were separate and were not linked to one another, or to any other software for instance that being done with the patient registration. A lot of these applications had basically been marked as "source" governments, and they were not courteous to assembly athwart the healthcare aptitude. This is the state that mechanization in healthcare found…… [Read More]

Medical Records

EMR

Electronic Medical Records

Electronic Medical Record (EMR) keeping can definitely add efficiency into the modern healthcare system. However, this efficiency might be associated with some hidden costs. One example of such a cost will be due to the loss of privacy that is allowed by shared records. Not only will doctors be able to see your entire medical history, but other agencies that you might not want to share information with will have access as well. Therefore, there are both advantages and disadvantages associated with the move to a digital system.

"Imagine a world where everything important about a patient is known to the physician the first time that patient presents," says Andrew Rubin, vice president for NYU Medical Center Clinical Affairs and Affiliates in New York City (Mann, N.d.).

Doctors have full access to a patient's medical health history has the potential to reduce errors and improve patient…… [Read More]

Electronic Health Records Case Study

Health Care continues to undergo fundamental change. Legislation such as the affordable care act has created a much higher percentage of insured citizens. Patent legislation is now allowing for much more competition for popular drugs. Generic drugs in particularly which are cheaper for consumers and much more profitable for producers are now eroding the market share of popular products. Even the use of cloud computing is changing the way care is administered within a facility. Even with these innovations, facilities still struggle with bloated cost structures, inefficient behavior, and lack of staffing. MGH is not different in this regard. It suffers from a large influx of patients with the inability to provide timely care. Below is a description of the issues combined with possible real world solutions.

Describe the current process and identify the specific areas that slow the process.

The current process has is inadequate primarily due to staffing…… [Read More]

EMR Organizational Change Plan Introducing Electronic Medical

EM

Organizational change plan

Introducing electronic medical records (EM)

Along with expanding health coverage to more Americans, one of the goals of recent federal policy has been the widespread adoption of electronic medical records (EM) by healthcare providers across the nation. "The federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records" (Abelson, Creswell, & Palmer 2012). Having EMs can be used by providers to gain swift access to comprehensive information about a patient's health history. Some patients forget their history of diagnoses or the medications they are on; sometimes patients must be treated when they are in a mental or physical state where they cannot be forthcoming with information and their friends and families are not nearby. Also, there is the problem of patients attempting to obtain more pharmaceuticals or drugs which they should not be taking. "Electronic…… [Read More]

Impact of the Electronic Health Records on Patient Safety in King Khalid University Hospital

Electronic Medical ecords (E-SIHI) in King Khalid University Hospital on Patient Safety

The objective of this study is to demonstrate the impact of e-SIHI (Electronic Medical ecords) on patients with regards to their security and safety. The King Khalid University Hospital has implemented the e-SIHI since May 2015 for all departments. Two weeks after the implementation, QMD (Quality Management Department) conducted an audit to measure a compliance for the system and ascertain whether the e-SIHI can improve health and safety of patients. However, the QMD found that there are many areas requiring improvement in the system. The paper discusses the methodology used to evaluate the system to ascertain whether e-SIHI is beneficial to the patient.

esearch Methodology

The research methodology reveals research design discussing the method of data collection, sample population, sample size, and project tool.

Study Design: The team audits the e-SIHI using a checklist to verify whether the…… [Read More]

Electronic Certificate of Medical Necessity

Electronic Certificates of Medical Necessity: A Proposal

Medical billing can now become a relatively painless process for the personal in a medical facility through the electronic filing of certificates of medical necessity (e-CMN). Manually filling out paperwork is very time consuming, and is not very cost effective. However, the technological advancements created in the area of medical billing are very efficient. While many offices now fax the CMN's, the incorporation of e-CMN's into the medical office and billing process, decreases overhead costs, reduces paperwork, and helps substantially with the on-going battle to comply with the ever-changing Medicare requirements. While each of the previous reasons is enticing enough to consider incorporating e-CMN's into the office routine, the increase of revenue is certainly a major benefit and is the direct result of the time reduction with the filing process.

Billy Tauzin, chairman of the U.S. House Committee on Energy and Commerce, clarified…… [Read More]

Medical Reconciliation and and Attached References

Barnsteiner JH. Medication reconciliation: transfer of medication information across settings -- keeping it free from error. Am J Nurs. 2005;05(3 Suppl):3-6.

This article evaluates the need for proper medication reconciliation across various nursing settings. This article is important as emphasis is placed on error free reconciliation which is very important for proper client service and treatment.

Bullough, Vern L. and Bonnie Bullough. The Emergence of Modern Nursing (2nd ed. 972)

This reference emphasized modern nursing and many of the practices and advances of nursing over the years. This is important as it provides a historical perspective of medical reconciliation. A historical perspective is needed to better understand improvements that will need to be made in the future.

D'Antonio, Patricia. American Nursing: A History of Knowledge, Authority, and the Meaning of Work (200), 272pp

This reference provides further evidence into the history of medical reconciliation and recommendations on improvements that should…… [Read More]

Medical Reconciliation

Nursing

Describe briefly your topic of interest (15 possible points):

According to the United States Department of Health and Human Services (2013), medical reconciliation is "the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions." The process of medical reconciliation falls within the rubric of electronic medical records, which enable medical reconciliation. Medical reconciliation saves lives, improves the efficiency of hospital administration and of the healthcare team, and is simply necessary for providing quality of care.

#1 Database (or collection) (30 possible points):

Title of source:

"Electronic Health ecord (HE)"

Location of source (UL): http://www.ihs.gov/ehr/index.cfm?module=medication_reconciliation

Owner or publisher:

Indian Health Service

The Indian Health Service (2013) offers an overview of what medical reconciliation is, and how it applies to both individual and community health.…… [Read More]

Records Have Been the Norm

It maintains these features for health information under the authority of "covered" units such as health care centre, plan or provider. Online storages such as Google Health and Microsoft Health Vault do not lie within the bounds of such kinds of units. This implies that their data is not as safe as they expect or assume them to be. The best approach to stay safe is to manage the electronic medical records in an online patient portal which works within the confines of the health care provider's information system. The private data which exists there will be covered by the terms of HIPAA. The level of access can be moderated to comply with the laws of the state. An instance of such a portal is the "PatientSite" created at the eth Israel Deacon Medical Center, oston. This kind of forum provides services such as secure messaging, registering appointments and updating…… [Read More]

Organizing Medical Records One of the Most

Organizing Medical ecords:

One of the most important factors for proper billing and coding starts with the development of a well-documented and organized medical record. This is largely because patients and health care providers are normally faced with the need of keeping and providing medical records. These individuals are usually responsible for providing copies of their medical records to health care specialists and consultants. In most cases, medical records are typically organized in various ways including:

Source-oriented ecords:

This is a traditional patient record model that maintains reports depending on the source of documentation with each source of data containing a labeled section known as sectionalized record. In this format, all documents created by the nursing staff are located in record's nursing section, medical section for physician-generated documents, and radiology section for radiology reports (Green & Bowie, 2010, p. 89).

Problem-oriented ecords:

This is a more systematic method of documentation…… [Read More]

Home Computerized Medical Records Computerized Medical Records

Home Computerized Medical ecords

Computerized Medical ecords

Advantages

One major advantage of computerizing medical records is that this method saves money and time for medical professionals. A traditional record system consists of files stored in a filing cabinet or other physical location. Files stored this way can easily become lost or displaced; the t time and resources to track down files that are missing can have a huge effect on the efficiency, effectiveness and revenue of the medical practice. Missing files can result in duplicate paperwork, lost time and productivity. For example, a medical office assistant that spends 20 hours a week searching for missing files, at an hourly rate of $15 costs the office over $14,000 a year in wasted time and money! Computerized medical records eliminate all these issues. With files kept in one database, they can be quickly located and retrieved. esulting in less rework and less…… [Read More]

Computer-Based vs Paper-Based Medical Records and Discuss

computer-based vs. paper-based medical records, and discuss which are better. ecord-keeping is an important and vital part of any medical practice. Keeping medical records ensures the health and wellness of patients by tracking their overall care and health history. ecord-keeping is important for many purposes including legal information, health information and documentation, and keeping information that must be shared for professionals that are documented caregivers for patients. Thus, determining the best method for keeping records is vital to the patient and clinics success.

Keeping paper-based medical records has been the standard for some time. Paper records provide a wealth of information. Only recently has the computer been seen as an effective tool for keeping medical records. Computers are now considered a confidential and safe tool for keeping medical records. There are many advantages of computer-based medical records. Computers have the ability to store a lifetime of health data in a…… [Read More]

Care Information Systems and Medical Records

Evolution of Health Care Information Systems Physician's Office Operation

Filling in the hole of health care information technology will endorse safe, capable, patient-centered, and patient care that is fruitful in a timely way. In this essay, the theme is to look into two modern health

care organizations and then compare and contrast many characteristics that will involve the kind of evidence systems are using at the moment, investigate the transmission of information 20 years ago and how the substitute of data today. Furthermore, this essay will cover two major events and technology developments that have inclined present Health Care Informational Services practices.

Compare and Contrast Doctor's Workplace Operation

These day's doctor's office operation is familiarizing to the health care reform that was sanctioned in 2010 by the Obama organization. During sometime in October of 2013, the exchanges in health insurance was available on the market for customers on order to…… [Read More]

Application of Electronic Health Records Systems

Adoption Of the EH Technology Systems

In a contemporary health environment, nurses have long been using the computer technology to achieve the health outcomes such as the laboratory tests, however, the EH (electronic health records) has become a revolutionary innovative technology for the enhancement of the healthcare system. It is very critical for nurses to understand their roles as an agent of changes and influence other to change the tradition way of doing things. My role as a nursing facilitator of a small hospital in New York is to prepare the implementation plan of a new EH system for the hospital. While the decision has been finalized for the implementation of the EH, nevertheless, there is still a resistance from the nurses of the hospital.

The objective of this paper is to use the five qualities of the oger (2003) model for the implementation of the new system.

Application of…… [Read More]

Optimizing the Use of Electronic Health Records

EH Assessment and Evaluation to Support Healthcare Outcome Objectives

The outcome-related goals that the tertiary care hospital seeks to achieve include the following: 1) Strengthen adult admissions screening at intake for pain, depression, and adverse health behaviors such as smoking, excess alcohol intake, and body mass index (BMI) greater than 30; 2) implement comprehensive geriatric assessment for all adults 65 years of age and over who are hospitalized for more than seven days or readmitted within less than three days following discharge; and 3) promote care team performance. The electronic health record (EH) is the default system for adult admissions, and it includes documentation standards and structures such as SOAP and checklists. Hospital staff are provided periodic guidelines through educational venues or through referral to the electronic policy and procedure manual. Given this information, the data elements that should be included in the EH assessment and evaluation screens are as…… [Read More]

Records Control in Healthcare One

' Since the paper is only used as 'back up' this means that the files are under lock and key, in a centralized location or in the department generating the data. They do not circulate throughout the facility, ensuring a greater chance of misplacement or security compromises. But even in this instance, errors can occur -- timely record-updating and writing times and dates next to new information when it is added to a patient's file is essential, to ensure that there is not a discrepancy between the patient's data kept in two different locations. In fact, one worker at one of the larger facilities expressed dissatisfaction with the paper back-up method: "Keeping everything together either electronically or on paper not both. Causes too much confusion," she or he wrote.

Unfortunately, in large and small facilities, even with security procedures such as password protections for digital data, safety concerns remain. Concerns…… [Read More]

Ruchi Tomar Disadvantages of Electronic

None of the findings are not surprising to a lot of experts. Apart from large systems that are integrated, like Kaiser Permanente in California and the Veteran's Administration, a lot of doctor practices are adopting different EMs. Also in so many different situations they do not talk to one another (Sittig & Singh 2012). So, a doctor's record is not necessarily able to get access notes from his regional hospital if different systems were utilized. A lot of doctors in that condition could just re-order a test, instead of going through all of the changes of finding the records from the hospital.

Actually many experts make the point that the true power of digital records come when using a sole, unified system that can be retrieved by altered health sites. With the exclusion of large combined health arrangements, there sometimes can be fragmented EMs. Experts mention that perhaps with the…… [Read More]

Communication Electronic Communication Has Become One of

Communication

Electronic communication has become one of the most important methods for people to communicate with one another in recent years. Spielberg (1999) noted that patients have sought to utilize electronic communication with their physicians. In the past, he argued, a variety of exchanges were utilized, including in-person visits, telephone, pagers and voicemail, so it was only natural that communication between patients and those within the medical profession would be extended to the realm of electronic communication. Thus, the market has driven the need for health care organizations to begin to explore how they can use electronic communication methods such as email, the Internet, online chats or even SMS messaging to bridge the communication gap with their patients. hile the market may demand new methods of communication be developed, there are risks inherent to the medical profession that present challenges or obstacles to facilitating the market-demanded electronic communication methods.

The…… [Read More]

EMR and Strategic Planning Electronic

In the formulating and implementing of strategies, the unique treatment plans for patients must also be taken into account. Only by combining electronic medical records and applying them to specific process areas can customization of treatment plans be created (Terrell, Terrell, 2009). The ability to selectively use medical records and continually refine processes to meet patients' expectations is critical for any strategic plan and continually executed tactics, initiatives and programs to be successful.

eferences

Anderson, C.. (2008). The Ins and Outs of Electronic Medical ecords. Applied Clinical Trials, 17(9), 50,52,54,56.

Miller, A., & Tucker, C. (2009). Privacy Protection and Technology Diffusion: The Case of Electronic Medical ecords. Management Science, 55(7), 1077-1093.

Terrell, G., & Terrell, T.. (2009). Cornerstone Health…… [Read More]

Health Care Situation Medical Error Due to

Health Care Situation: Medical Error Due to Doctors' Bad Handwriting

Identify a health care news situation that affects a health care organization such as a hospital, clinic or insurance company.

I have identified the following health care news situation as the topic of my paper: "Poor Handwriting of Doctors and its implied risks for the Patient, Hospital and Medical Malpractice Insurance." Poor handwriting of physicians resulting in poor legibility of entries into patients' medical records carries very dramatic risks for all above-mentioned interest bearers. It can result in severe health danger for the patient and - in extreme situations - even cause a patient's death. Doctors' bad penmanship has long been seen a problem within organized medicine and the patient safety movement. Three American Medical Association (AMA) policies dating back to 1992, urge doctors to "improve the legibility of handwritten orders for medications" and review all orders for accuracy and…… [Read More]

Transformation of Electronic Billing Systems From Military

ransformation of Electronic Billing Systems From Military Use to Public Medical Facilities

he advent of the twenty first century brings with the new dawning a time of extraordinary technological advancement, mega informational system development, and expanded scientific discovery. Without argument, these new developments bring with them an explosion in the informational database that must be reconciled and dealt with. No longer can service organizations and businesses rely on a central data base for gathering storing and retrieving information as these type of systems are unwieldy - and becoming more so. Individuals responsible for budgeting, marketing, invoicing, and consumer demographics are in need of immediate and accurate, ready-to-use, and updated information with respect to services and/or products offered. Unfortunately the healthcare industry has been slow in updating information retrieval systems in keeping with the need for immediate patient information retrieval and the dearth of new information being created.

he majority of…… [Read More]

Patient Electronic Access Implementation Plan

Patient Electronic Access

The objective of this study is to investigate the application of the electronic health record at the inner City health hospital. The goal of implementing the program is to allow patients to have easy access to their health data and information to assist them sharing their health information with other healthcare and personal care providers. This study investigates the application of Measure 1 Stage 1 for the City Health organization. Following the benefits of the electronic health records, the City Health has decided to implement the new program. The program will allow patients to access their information on demand through PH (personal health record). However, the City Hospital will be able to derive benefits from the program by setting aside $170,000 for the implementation costs and $90,500 maintenance expenses. Moreover, the City Hospital should organize a training program for the staff to make the program be successful.…… [Read More]

Lack of Creativity in the Medical Profession

intended public audience for this opinion piece includes stakeholders in the healthcare industry, including educators, researchers, nurses, physicians, and hospital administrators. One of the goals of this opinion piece is to persuade members of the healthcare industry to embrace a new paradigm in which creative thought is welcomed and encouraged, rather than shunned and mistrusted as it currently is. Consumers who are willing to pressure their physicians to improve quality of care are also a primary target demographic, as all Americans will at some point in their lives avail themselves of medical services. All Americans are likely to have had, at some point or another, a negative experience using medical services. Therefore, my goal is to persuade the audience of consumers to demand a higher standard of care.

The popular television show House helped draw attention to the need for, and resistance to, creativity in the medical practice. A lack…… [Read More]

Chief Medical Information Officer Cmio

The theory has three factors:

Valence

Instrumentality

Expectancy

Equity Theory -- Stated that a person compares their outcomes and inputs with others. Sarah has a meeting to discuss the salary of the whole entire organization. They realized that women were low paid in comparison to the men. Sarah started comparing herself with one of her colleagues saying that she worked harder than him and she has been there longer than him.

Satisfaction performance theory -- Porter and Lawler (1968a) state that it is not a motivational model that had dealt with the relationship between satisfaction and performance. Sometimes any reward that an employee may get is not related and how well he/she performs their job. Although this case does not tell us what type of reward Sarah was getting for her job we can see that her level of satisfaction she had when doing her job. She perceived that a…… [Read More]

Patient Handoffs Majority of the Medical Errors

Patient Handoffs

Majority of the medical errors take place in the patient's handoffs. A shift among the doctors is a common practice. There are a number of old patients who approach around 16 different doctors in a year, while young patients who are healthy refer to normal physicians and to specialists as well (Philibert, 2008). In a hospital normally, less attention is given to the patient by his primary doctor, while the trainees and the hospitalists are more involved in that patient. Patients are rotated to different doctors with an average of fifteen times in a five day stay at the hospital. Young doctors often accept appointments of more than 300 patients in a month, in their initial training period just because of time pressure (Chen, 2009, p. 1).

Alteration that have been brought about in the patients care have increased the quality of the services that are offered to…… [Read More]

Electronic Database for Records Medical Division

Medical Affairs Department: Implementing Electronic Database Record Keeping

Feasibility Analysis:

This project is very feasible as it is a standard updating of record keeping procedures from manual to electronic database -- which is common practice among most records departments today. There is nothing exceptional or impractical about this project and it can be accomplished with relatively little cost, little time devoted to the transition, and few risks.

Technical Feasibility: The project is technically feasible and depends only upon the assistance of the IT division and the training staff/support system to help in the going-online phase of the transition. The database technology is standard for the industry and will be easily obtained and implemented.

Economic Feasibility: The project is economically feasible with systems ranging from low-cost to higher-end or premium packages. A medium-range database system will be sufficient for this project and is within the budget of the Department and can…… [Read More]

Medical Writing Boon and Bane'

These examples highlight that technology is always a tool, a way of enhancing human judgment -- we must not mistake it as a replacement for good nursing practice.

After all, the use of a computer is no substitute for a medical education. Anyone who works in a hospital can see this -- the increased accessibility of information through the Internet also means that patients often come in, convinced that they are suffering from a serious illness, allergy, or condition, based more upon a diagnosis Googled on WebMD, rather than upon the fact that they saw a doctor! If a computer alone was required to diagnose, everyone would have a degree!

Don't get me wrong -- I use technology every day in my life, and thank my lucky stars, and my patient's lucky stars, that it is so ubiquitous. When health care providers wish to communicate, the use of cell phones…… [Read More]

Medical ID Theft and Securing Ephi Medical

Medical ID Theft and Securing EPHI

Medical Identity Theft

Medical information can be stolen by 1) the bad guys getting sick and using a victim's information to obtain services, 2) friends or relatives use another friend's or relative's information to obtain treatment, 3) when professionals, such as physicians, fabricate services that did not exist, 4) organized crime, and 5) innocent or not so innocent opportunists (Lafferty, 2007). ad guys that get sick can take a victim's insurance information to obtain services for treatment. Professionals can fabricate false claims to cover medical errors. Opportunists have access to patient data and the ability to steal, use, or sell that information.

Effective security requires clear direction from upper management (Whitman). Assigning security responsibilities and access controls with audit controls to organizational elements and individuals helps to place accountability on individuals. They must formulate or elaborate security policies and procedures based on the organizational…… [Read More]

Government Created a Committee an Electronic Health

Government Created a Committee

An electronic health record is a digital record of a patient's health information generated from every medical visit a patient makes. This information includes the patient's medical history, demographics, known drug allergies, progress notes, follow up visits, medications, vital signs, immunizations, laboratory data and radiological reports. The EH automates and streamlines a clinician's workflow. (Himss, 2009)

Due to the multiple advantages of an EH, health care agencies have been aiming to push up this technology. In 2004, the FDA approved of an implantable EH microchip into patients. Each microchip has a specific code which is identified through sensors. The device is implanted under the skin, in the back of the arm, requiring a twenty minute procedure, without needing the use of sutures. ("Fda approves computer," 2004)

According to the Center for Disease Control and Prevention, deaths due to preventable medical errors rank as the fifth most…… [Read More]

Ethical Issues Surrounding the Adoption of Electronic

Ethical Issues Surrounding the Adoption of Electronic Health Records (EHR) by Health Care Organizations and Meaningful Use

The objective of this work in writing is to examine why health care organizations are hesitant to adopt electronic health records (HER) in light of the potential of HER to improve quality, increase access, and reduce costs. This issue will be examined from a legal, financial, and ethical standpoint and in relation to 'meaningful use'.

The use of information technology in the health care field shows a great deal of potential toward improving quality, efficiency, and safety in medical care. (DeRoches, Campbell, and Rao, 2008, paraphrased; Frisse & Holmes, 2007, paraphrased; and Walker, et al., 2005, paraphrased) The American Recovery and Reinvestment Act (ARRA) of 2009 is reflective of the unprecedented interest of the Federal government in the area of bringing about increases in the use of IT in health care for system…… [Read More]

Schneck Medical Center The Baldrige Award Schneck

Schneck Medical Center: The Baldrige Award

Schneck Medical Center: Overview

The Schneck Medical Center according to the National Institute of Standards and Technology -- NIST (2011) "is a 93-bed nonprofit hospital providing primary and specialized services to the residents of Jackson County, Ind., and surrounding communities." The facility as NIST (2011) further points out, offers a variety of primary care services including but not limited to cancer care, noninvasive cardiac care, and joint replacement.

Established in 1911, the facility was amongst four organizations selected by the President and the Commerce Secretary in 2011 to be awarded the Malcolm Baldrige Quality Award. This particular award in the words of NIST (2011) is "the nation's highest Presidential honor for performance excellence through innovation, improvement and visionary leadership." It is important to note that apart from the Baldrige Award, Schneck Medical Center has been a recipient of several other awards including the Outstanding…… [Read More]

Security of Health Care Records

" (Harman, Flite, and ond, 2012) the key to the preservation of confidentiality is "making sure that only authorized individuals have access to that information. The process of controlling access -- limiting who can see what -- begins with authorizing users." (Harman, Flite, and ond, 2012) Employers are held accountable under the HIPAA Privacy and Security Rules for their employee's actions. The federal agency that holds responsibility for the development of information security guidelines is the National Institute of Standards and Technology (NIST). NIST further defines information security as "the preservation of data confidentiality, integrity, availability" stated to be commonly referred to as "the CIA triad." (Harman, Flite, and ond, 2012)

III. Risk Reduction Strategies

Strategies for addressing barriers and overcoming these barriers are inclusive of keeping clear communication at all organizational levels throughout the process and acknowledging the impact of the organization's culture as well as capitalizing on all…… [Read More]

Complying With Health Record Codes

Provider Document Guidelines)

Provider Documentation Responsibilities

Summary of Key Concepts

Authentication of patient record entries

All entries in the medical record must contain the author's identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.

Abbreviations used in the patient record

All abbreviations use should be kept to an absolute minimum for effective and safe communication in patient care. Abbreviations should be avoided completely especially in drug prescriptions, operation lists and consent forms -- for example, the laterality of site of operation. Lists of approved abbreviations and their correct meaning should be established along with a list of 'Do not use' abbreviations to be followed by the healthcare professionals.

Legibility of patient record entries

The record must be legible to someone other than the writer. All entries must be legible to another reader to a degree that a meaningful review may be conducted. All notes should be…… [Read More]

Improving Computer-User Interface in Medical Care the

Improving Computer-User Interface in Medical care

The use of computer information systems in the field of medicine has revolutionized the way patients receive medical care. Computer information systems have assisted medical practitioners to capture and transfer information quickly saving the time taken to treat patients. Storage of information has also been automated such that the medical personnel do not have to manually input and store the data. The management of medical organizations has been able to improve on the time take to diagnose an ailment and the accuracy of diagnosis. The presence of electronic health records in an organization improves the way the organization collects patient's information. The collection of debt is thus automated and accurate thus the medical organization can collect all its debts.

Computer user interface refers to the method used the organization to connect o the computer information system. This interface needs to be improved to ensure…… [Read More]

Privacy Violations and Malpractice at the Okc VA Medical Center

Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma

Today, the Department of Veterans Affairs (VA) operates the nation's largest healthcare system through the Veterans Health Administration (VHA), including 152 medical centers (VAMCs), 800 community-based outpatient clinics and numerous state-based domiciliaries and nursing home care units (About VA, 2016). As the second-largest cabinet agency in the federal government, the VA's budget exceeds the State Department, USAID, and the whole of the intelligence community combined) with more than $60 billion budgeted for VHA healthcare (Carter, 2016). One of the VHA's largest medical centers that provides tertiary healthcare services to eligible veteran patients is the Oklahoma City VA Medical Center (OKC VAMC) in Oklahoma City, Oklahoma. Like several other VAMCs, the OKC VAMC has recently been implicated in a system-wide scandal concerning inordinately lengthy patient waiting times and misdiagnoses which may have contributed to the deaths of some veteran patients and jeopardized…… [Read More]

Patient Records New York City

The author also explains that the data stored in the system can be used to help public health officials identify medical issues facing the community as well as track various trends from the community and public health perspectives.

Article Relevance

(How does this article relate to you as doctor?)

As a physician, I recognize that my time will be in very short supply. Therefore, any system or resource capable of saving time and increasing the efficiency of the healthcare services that I provide will be greatly appreciated. Similarly, patient safety, elimination of medical errors, and patient outcome are always paramount concerns for any physician. Therefore, I would welcome the opportunity to use EHR systems to the extent they address those issues positively. Moreover, as a physician, I am always interested in any approach that might be beneficial to human welfare and community and public health issues. According to the article,…… [Read More]