1. COMPUTERIZED PHYSICIAN ORDER ENTRY DERRICA WRIGHT HCIS/255C Computerized physician order entry is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff or to the department’s pharmacy, laboratory, or radiology responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at the point of care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges. CPOE is a form of patient management software.
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.
Running head: NUT1:NURSING INFORMATICS:TASK 2 NUT1:Nursing Informatics:Task 2 Western Governors University NUT1:Nursing Informatics:Task 2 Section A Computerized medical record increase quality of care in many ways. First, it is a way that your medical records could be electronically viewed from one doctor to another without the need to wait for transfer of records or the need to copy records and hand carry them to another doctor. Second, they help reduce errors in orders due to the inability to decipher handwriting. Also, if you are in the hospital, your doctor can view your test results and give orders via computer from either his home or office. ( Lee, A. C. 2013).
This system provides additional confidentiality for the patient’s chart and saves time in retrieving and refiling records quickly. The medical assistant can check the cross-reference system by typing the patient’s name into the computer, locating the patient’s chart number, and retrieving the paper record from the shelf. Electronic Medical Record systems used in the office may include options that allow both the patient’s demographic information and the patient’s medical records to be accessed from the same software system. 4. The color-coding system uses color to visually narrow the area of search for a specific record.
This complex new system has ways of looking up patient history and pharmaceutical information if a drug is not known. Physician orders were now legible and properly sent with the new computerized physician order entry (CPOE). There were issues with the start of the system to locate beds that patients were listed in and how to get labs done from the Lab tech being paged through a paging system. Patient Access Reps, Doctors, and Nurses were now able to use “work station on wheels” (WOW) where portable laptops were used to triage and register a patient rather than the use of
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
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
Consumers are more interesting in the way technology has advanced with in the health care era. Patients are aware that all medical information is safely kept in a computer, but are concern of possible typos or errors that happens with the use of computers. On the flip side consumers understand that retrieving the health information can be done faster for test results and other important information that may usually take weeks to retrieve. Consumers now know it is easier for them to request refills on medication, and sent to the pharmacy quicker. Consumers realize medical providers are gaining a better way to manage the medical information, which will help improve the health care industry, and provide positive medical care.
With the emergence of the electronic health (EHR) record, decision support, and expert systems, the health care arena moved to an era of information-managing technologies (Englebardt & Nelson ,2012). Expert systems are used in hospitals for interpretation of patient data through a large database. The pharmaceutical expert system helps in identifying harmful drug to drug interactions whereas laboratory expert system alerts nurses and doctors of critical lab values. An expert system in one hospital system has been credited with remotely analyzing new data, upon discovering a problem, automatically alerts the doctor by a text message eliminating the doctors' need to have access to the computer to get the results. References Englebardt, S. P., & Nelson, R. (2002).
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. These applications, modules, or websites are used by the patients of healthcare organizations to gain access to their personal health information. In order to access their personal health information, the individual has to set up a username and password. After they have set up their username and