Therefore, the EMR includes the standard clinical and medical data collected in the provider’s office that includes a coherent and more comprehensive patient history. For instance, EHRs are intended to share and also contain information from every provider who is involved in the patient’s care (Moczynski, 2009). Markedly, EHR data can be managed, created, and consulted by staff and providers who are authorized by various healthcare organizations. In addition to keeping patient records, doctors and nurses are able to access and retrieve information easily using EMR. EMR contains the treatment and medical history of patients in one practice.
Definition of Terms Definition of Terms The following information includes terminology, its definitions, and a brief description of its application to the health care field. Health care professionals are expected to know and understand the applicable terminology in the efforts to deliver the best quality services. Technology has evolved with time and the changes and demands of our health care system require computerized information systems to help organize, maintain, and exchange pertinent information. Ambulatory Medical Record Ambulatory Medical Record, (AMR), is electronically stored medical records that are not an overnight stay or in a hospital setting. This includes urgent care centers, physician offices, and services provided in
Communication incorporates the basic elements of communication; meaning there are so many cultural differences, personalities, languages, beliefs, values, morals, and behavior. This is why establishing positive communication along with understanding cultural differences will allow professionals to understand the patient while focusing on his or her need of care. Communication in the health care industry starts the minute a physician meets with the patient on the very first visit or with the receptionist the minute a patient walks in the health facility. When communication is established it should be maintained at all times and on all levels whether it is verbal or non-verbal. Effective Communication takes place through direct communication, voice messages, e-mailing, filling prescriptions, phone calls, memos, letters, and making appointments.
Is this saying valid? Could there be a solution to prescription fraud or abuse? Some would say yes, some would say no, but others would present you with E-prescribing. E-prescribing can be defined in many different ways. NHS Connecting for Health described it as: The utilization of electronic systems to facilitate and enhance the communication of a prescription or medicine order, aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trail for the entire medicines use process.
Documentation of the nursing care plan is important in order for the patient to receive proper care. All health team members can refer to the record to carry out the necessary steps within the plan (Module 6: Nursing Care Plan, 2012). A nursing care plan is defined by the nursing process. This process involves a scientific approach to problem-solving concerning patient care. The nursing process is individualized to each patient.
There are many benefits of utilizing a patient portal, capabilities of a patient portal, and how it affects EHR access for consumers, healthcare organizations, and their employees. By the time you reach the end of this paper, you will have complete understanding of everything a patient portal has to offer its consumers and healthcare professionals and organizations. You may be asking yourself, “What is a patient portal and how is it going to benefit me?” The answer is not as complex as you might think. A patient portal is an online application and/or secure website that patients can use as an alternative form of communication between themselves and their provider. Some portals are modules that are added onto an electronic health record system, while others are used as stand-alone websites, and others are integrated into the existing website of a healthcare organization.
The purposes of electronic medical records are for assisting professionals in the healthcare to store and share patient information across disciplines as well as across facilities. Electronic Medical Records are used by “professionals including different levels of providers because they can be assessed from different locations simultaneously, diagnostic images can be viewed from various locations allowing for continuous of care use electronic Medical Records in the health care systems. Electronically stored client records provide quick access to clinical data for a large number of clients and it has prompts to ensure that key information is noted as well as reminders of when labs and vaccines are needed.” (Hebda & Czar, 2013, p. 28). Electronic Medical Records “enable nurses in their varying roles across the continuum of care to create a single narrative for each patient, tracking progress from admission through discharge and within ongoing care in the ambulatory environment.” (Deese & Stein, 2004, p.337) Deese, D., & Stein, M.
On the surface, just being able to simply send the basic patient chart to another doctor in the practice, the front desk, the nearest hospital or even a specialist is an improvement on the current paper process (Source One). However, even more important than ease of use, is the ability of the EMR software to track patient systems across multiple providers in the same practice or across hospital in an entire integrated health network (Source Seven). The physicians would have the option to view other patient charts with similar patient symptoms to a patient they were currently treating in real-time, which would allow them to see what they were ultimately diagnosed with, potentially saving the life of the patient on the table. It could essentially cut out the ‘learning curve’ of that doctor, especially if it was a set of symptoms that they were not as familiar with (Source Sixteen). Further, the EMR software is capable of alerting the doctors to trends that are taking place across the health system, making them aware of current bugs that may be floating around the area, which can help with quicker, accurate treatment of diseases and illnesses (Source
A patient can go into a doctor’s office for the first time and with the advent of electronic records, the doctor is able to access the patient’s record and compile the history of the patient’s health and problems that are specific for that individual. This information also creates a database of individuals with similar illnesses that can be used as tools to build knowledge in the illness and how to treat
EMR systems link all the various sections within an organization and include all data found within those sections. The reason behind this decision is because all forms of data and information will be transitioned to become electronic versions. This would eradicate the dreaded doctor hand writing which can lead to major problems when deciphering prescriptions and instructions. The information received, via hand held device or data entry specialist will be automatically uploaded into a new database that will house all the information. Essentially, EMR systems provide more efficiency measures and provide a more productive work place Data Governance Data governance (DG) refers to the overall management of the availability, usability, integrity, and security of the data employed in an enterprise.