Carol Alborn HIM CORE Day 11 9/12/2011 Purpose and Function of the Health Record A health record is a virtual storage place that documents health care services from healthcare providers at various locations such as the DR.’s office, nursing homes and ambulatory service locations. It’s made up of data or facts from the patient and family members, and these healthcare services, which is analyzed for useful information. It is the HIM professional’s responsibility to take data from traditional practice forms and any Personal Health Record (PHR) or from any other sources, then enter data into the Electronic Health Record (EHR) system. Anything missing can alter the patients care. Its Primary purpose is to ensure quality patient care and managing the cost of that care.
Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to: Track data over time easily identify which patients are due for preventive screenings or checkups check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations monitor and improve overall quality of care within the practice But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.
ABSRTACT Electronic Health Records (EHR) were designed to store valuable patient information and have taken the place of paper health records. Everything about a patient is included in an EHR, from medical history and treatments received to insurance coverage and test results. An EHR is a computerized system where patient records are created, used, exchanged, stored, and retrieved. It replaces the traditional paper records with an electronic record and maintains all of the elements of a paper record. The EHR is a computerized electronic record of patient health information generated by one or more encounters in any care delivery setting.
Personalize medicine has changed the concepts of patient care. Personalize medicine has began to revolutionized the healthcare field; in treatment, managing healthcare issues and treating diseases. Each patient’s needs are different and their treatment is based on individual needs. According to www coriell.org, Personalized medicine Personalized medicine is determined by many factors: the genetics we inherit; our innate personal traits of race, age and gender; our individual behavior; our family and community networks; and at the macro level, our economic, cultural, and environmental conditions.1 When most people think of personalized medicine, they assume it is everyday prescriptions received from family doctors; however, personalized medicine deals with gathering ones genetic information and combining that information with clinical data to modify drugs and doses to meet the patients’ needs. There is a variety of benefits, drawbacks and limitations in the use of personalized medicine.
Introduction to EMR at New York Hospital How going electronic affects nursing staff and patient care WGU NTU1 Task #1 The Electronic Medical Record (EMR) and New York Hospital • Use of computers at NYH is not a new concept – Currently, access to lab results, some patient orders and nursing assessments can be found online – Additionally , we access many scanned documents online to support patient care – But is this an EMR? No, not quite! The Electronic Medical Record (EMR) and New York Hospital • Implementation of a true electronic medical record is a cultural and conceptual shift to patient care order entry, clinical documentation, organization and access to patient care data as well as security, storage of data as opportunity to provide excellence in patient care. The Electronic Medical Record (EMR) and New York Hospital • Access to an individual’s patient care, financial and demographic data and use of analytical tools designed to collate information from all patient data collected across the continuum will be an important tool for strategic future planning, research opportunities and fiscal accountability as well as complying with new federal, state and regulatory requirements. • Computers and numbers go hand in hand.
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.
Critical Incident Medication Errors Seth Molin December 14, 2013 HMGT 320 University of Maryland University College Professor Ben Smith Medication errors are a dangerous and costly event. It is estimated that 1 million medication errors happen each year. Additionally, it is estimated that these errors result in approximately 7,000 unnecessary deaths (Binder, L., 2013, September 3). Jeannell Mansur from the Joint Commission International illustrated that “every hospital patient may be subjected to as much as one medication error each day.” In addition to the risk to patient safety these errors produce additional medical costs of an estimated 3.5 billion dollars a year. It is vital that steps be taken to mitigate this preventable critical incident.
These information systems, now driven by technology, provide an overall structure to illustrate the widespread organization of health information across computerized systems and its protected swapping of information amongst consumers, providers, government and quality control agencies, and insurance companies. By definition, Health information technology (HIT) is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making” (“Health information technology,”2013). In relation to HIT, technology symbolizes computers and communication qualities that can be networked to build techniques for transferring health information. Another crucial facet of
Electronic Medical records contain a range of data including, billing information, demographics, age and weight, medical histories, vital signs, medication, allergies, immunization, radiology images, and lab results. It is a complete patient record that allows streamlining and automation in the health care setting. Electronic medical Records increase safety through, evidence based decision support, outcomes in reporting, and in quality management. Electronic Medical Records have made a huge impact on the health care field. By moving patient records to computerized system it has improved efficiencies for patients, health
Smart Pumps: The smart choice for medicine Medication errors are extremely dangerous and potentially deadly to patients. According to a recent release of the Institute of Medicine’s (IOM) report, preventing medication errors, they found that medication mistakes injure more than 1.5 million patients each year. Also, that hospitalized patients are at risk for at least one medication error per patient day (IOM, 2006). Traditional infusion devices make it easy for clinicians to commit these errors. There are no safeguards in place and the infusion devices are often shared between many patients with extremely different infusion needs throughout the day.