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 on….

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 care. In many cases….

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 itself….

Medical Records
Each individual/entity in this scenario has an agenda. Sandra: is a child under both State and Federal Law; her immediate concern is hiding her sexual abuse by her stepfather; however, hospital administration must be concerned with her best interests on three counts: first, because she is a patient; secondly, because she is a child; third, because she is an allegedly abused child. Mrs. Anderson: is both the patient's parent and a mid-level hospital administrator; her immediate concerns are obtaining and editing medical records to keep her family together on religious grounds; however, the patient's best interest, both as a patient and a child, conflict with Mrs. Anderson's concerns. The hospital: is bound by both Federal and State law; its immediate concerns are serving the bests interests of its patient, who is also a child, while honoring Mrs. Anderson's rights as a parent/representative of the minor patient. In this….

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 and….

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 that contains four components i.e.….

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 time wasted.

Another key….

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….

Records of full medical operations are stored in primary storage facility, and are filed numerically in an attempt to realize efficiency. The filing system of an organization is usually numerical, and is based on terminal digits of the patient's HRN (Health Record Number). An up-to-date copy of the Paper-based medical records register should be kept in the file at all times. This may be the system used most of the time to locate medical records but it also provides a system to search when the power fail. Ideally, two-colored coded number of stickers are placed on the protruding right hand side back cover, of the medical record cover. These numbers normally match the last numbers on the HRN on the register. The digits that are colored, and in the case where they are misplaced, then it will show that the charts are misfiled. Ideally, file location can be determined….

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,….

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 have….

' 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 about….

Medical Abbreviations
How can eliminating abbreviations reduce errors?

In the medical profession, time is everything. To make documentation as expeditious as possible, a series of abbreviations have been accepted in records. This has been considered an acceptable practice as much as calling a registered nurse an "RN." The problems occur when people are unclear about the abbreviations mean or if a set of letters can have more than one meaning. For example, there is the abbreviation "CA" which means cancer and then "Ca" which is calcium. Another example is "a" which can mean both "artery" and "before" (Medical 2011-page 1). It is very easy to misread abbreviations when medical staff is in a hurry. Imagine the problem if a "q.w." which is take weekly was confused for a "q.v." which is take as one wishes. If the terms were written out rather than abbreviated, these potentially dangerous situations could be completely avoided.

Should….

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 be made to the process.

4.….

Health are -- Medical Retention Laws
Medical records retention requirements, whether Federal or State, are apparently aimed at maintaining records for a significant length of time after a patient's discharge. HIPAA does not impose a specific requirement for retention of a patient's medical records and leaves that task to State legislatures. alifornia meets and far exceeds Federal requirements in multiple requirements from multiple laws. Meanwhile, Nevada takes a far simpler tack while still adhering to Federal requirements.

Federal

HIPAA does not impose a length of time for which patients' medical records must be retained (U.S. Department of Health and Human Services, 2009); rather, that requirement is left to the states. However 45 .F.R. §164.530(j) does require that an entity governed by HIPAA must retain its "privacy policies/procedures, privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented" (U.S. Department of Health and Human….

Electronic medical records, which refer to medical records that are not only stored in electronic systems (which includes almost all medical records in the modern world, with the exception of some medical records maintained in non-industrialized nations), but that are accessible to multiple healthcare providers across different platforms.  The question is whether these records are able to improve quality of care by allowing healthcare providers to get a full picture of a patient’s medical history, as well as any presenting concerns or issues, as soon as the patient presents for medical treatment.  It would seem like the....

1. The benefits and challenges of switching to Electronic Medical Records in healthcare settings.
2. The impact of Electronic Medical Records on patient care and outcomes.
3. The role of Electronic Medical Records in improving healthcare efficiency and reducing costs.
4. The importance of data security and privacy in Electronic Medical Records systems.
5. The potential for interoperability and data exchange between different Electronic Medical Records systems.
6. The future of Electronic Medical Records and the potential for advanced technologies like artificial intelligence and machine learning.
7. The ethical considerations and implications of Electronic Medical Records, particularly in regards to patient consent and data sharing.
8. The....

Impact of Electronic Medical Records on Patient Care

The benefits and challenges of using electronic medical records (EMRs) in healthcare delivery
How EMRs have improved the accuracy, efficiency, and accessibility of patient information
The role of EMRs in reducing medical errors and improving patient safety
The potential risks to patient privacy and security associated with EMRs
The impact of EMRs on the patient-physician relationship and trust

Technological Considerations for EMR Implementation

The key technological requirements and challenges for successful EMR implementation
The different types of EMR systems available and their respective strengths and weaknesses
The importance of data interoperability and standards....

Research-Based Essay: Impact of Nurse-to-Patient Ratios on Patient Outcomes

Introduction

The nurse-to-patient ratio is a key factor that influences patient care quality and outcomes. Extensive research has demonstrated a strong correlation between lower nurse-to-patient ratios and improved patient outcomes, highlighting the critical role that nurses play in providing safe and effective care.

Evidence

Reduced mortality: Studies have shown that patients cared for by nurses with lower caseloads experience lower mortality rates. A study published in the Journal of the American Medical Association found that for every additional patient assigned to a nurse, the risk of in-hospital mortality increased by 7%.
Shorter hospital stays:....