Its Primary purpose is to ensure quality patient care and managing the cost of that care. Its secondary purpose as defined by the Institute of Medicine (IOM) deals with individual users for education, regulations, policies and public health from data entered, verified, corrected or analyzed directly or indirectly. Homeland Security has recently been added to the list of users, including patient care providers, managers and staff, coders and patients themselves. Patients can make changes as necessary. Other users might include lawyers, employers, law enforcement and researchers.
For example when patients are admitted or wanting to consult a health practitioner, information from the patient is required such as their name or previous illnesses, this process is called the admission interview. The history taking interview revolves around the collection of information regarding the patient’s medical history. As an example patients are required to provide information on their hereditary and family background in the event of diseases such as cancer being evident in members of their family, the actual patient’s medical history (e.g. previous surgeries or procedures) and the current state of their health (Faure, C 2008:267, 268). 2.2 An admission interview is crucial in any situation where the patient is seeking a consultation or where they have to be treated.
Situational AnalysisThe context of the steroid pulse therapy document is mainly focused on medical research. Primarily, it is written in relation to this type of therapy for patients who receive this treatment and the ones who administer the therapy. The request for the research proposal is addressed several times throughout the document. For example, in the background of this document, the author acknowledges that “Nursing instructions are important for improving patient knowledge related to their diseases and treatments.” The document was clearly written while the therapy treatment was being conducted on separate occasions. This is evident by a few
By providing an efficient intake process, a certain flow can be maintained to move the process along smoothly and more organized. If any of the processes are not organized there will be a lot of confusion and unhappy patients. Patient satisfaction should be a step that is included in any health care facility. The patient intake process usually began when a patient calls to schedule an appointment. This is usually where the patients personal information is obtain such as their name, phone number, date of birth, address, reason for the appointment, name of health care coverage and referring physicians if there is any.
The EHR is a computerized electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates the clinician's workflow and has the ability to generate a complete record of a patient encounter - as well as supporting other care-related activities directly or indirectly, including evidence-based decision support, quality management, and outcome reporting. In this paper I will discuss the many benefits and drawbacks of EHR’s, the types of software used and their functions as well as my thoughts on the future of Electronic Health Records. Many healthcare organizations have switched over to electronic health records since President George W. Bush called for health records to be stored electronically by 2014, and President Obama’s administration plans to continue pushing for that deadline.
The traditional approach includes collecting subject matter on “biographical data, present health concerns (or present illness) and the chief complaint, past history, family history, review of system and patient data” (Farrell & Dempsey, 2010, p. 74). The assessment interview builds the foundation of the nurse and patient relationship. Building good rapport with the patient will alleviate any stress, anxiety or discomfort the patient may be feeling. The patient will be asked personal questions and at times may not understand or may not want to divulge information about their personal life/situation. As a nurse being open and honest, explaining why this type of information is necessary and asking open-ended questions will help prompt the patient to disclose the facts required, expedite the process and be fundamental in performing a successful assessment (Springhouse, 2004).
Amy Bauer 16 February 2011 SCI 115 Professor: Susan Kennedy Personalized Medicine Personalized medicine is a medical model emphasizing in general the customization of healthcare, that have decisions and practices that are being tailored to individual patients in whatever ways possible. Recently, this has mainly involved the systematic use of genetic or other information about an individual patient to select or optimize that patient's preventative; extension of traditional approaches to understanding and treating illness. Since the beginning of the study of medicine, physicians have employed evidence found through observation to make a diagnosis or to prescribe treatment. In the past, this was presumably tailored to each individual, but personalized medicine makes treatment more specific. Over the years of medical care have been focuses on standards of care based on studies.
WHAT IS AN ELECTRONIC MEDICAL RECORD (EMR) ? An Electronic Medical Record (EMR) is a way of storing patient information on a computer. EMR have a similar structure to the paper-charts, and these contain all the information that is relevent for the treatment and nursing of a patient. The EMR includes both clinical information: such as diagnosis, allergies and medicines; and a demographic information, such as: personal information, for non-clinical use- an example of such information is the patients’ health number that is given to him/her when he/she visits the hospital for the first time. The records contain information that is used for different purposes: 1) Administrative tasks: Registering patients Scheduling appointments 2) Clinical practices (diagnostic & therapeutic decisions): Computerized prescriptions Lab tests Diagnostic measures Progress notes from different healthcare providers 3) Research practices QUALITY BENEFITS OF AN EMR Assessing data from paper medical records is time-consuming because it involves reviewing information manually — record by record.
The change is the way of making a correction. Usually the correction is by way of an attachment to an EMR. Separate from the paper medical record, a new document is created showing the correction(s) and computed to the EMR with a computer code as a reference to indicate as an attachment to the original document. An electronic signature is required to confirm the attachment. (McWay, 2003, p.73) Question 2: When should the patient be advised of the existence of computerized databases containing medical information about the patient?
Medication will also be recorded so as not to give out the wrong dose. Provide evidence of care required, intervention by nurses or doctors and patient or client responses. Provide a baseline record against which improvement or deterioration may be judged. Show evidence of on-going assessment and treatment and reasons for carrying it out. Discuss and agree with service users what they are going to record about them.