HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples
Electronic health records and the ability to exchange health information electronically can help you provide higher quality and safer care for patients while creating tangible enhancements for your organization. Electronic health records help providers better managed care for patients and provide better health care by providing accurate, up to date, and complete information about patients at the point of care. It allows quick access to patient records for more coordinated, efficient care for the patients by the office. We will be able to send messages between the office to patients and other physicians’ offices. Patients will be able to access their information and get their lab results with ease. HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples.
This will improve patient and physician communication while creating lasting relationships and trust with the office. The patient’s records will also be more secure due to the fact that there will be no paper copy that can be stolen or lost allowing others access to the records and important personal information.
Electronic Health Records will assist physicians and their staff to reduce the medical errors while providing better and safer care for their patients. It will allow providers to better diagnose patients which will in turn help the safety of the patients.
The provider will be able to prescribe medication easier while also being able to note what medication the patient has been on and the possibility of a patient abusing medications to help reduce the abuse. The prescription will be more reliable because the human error factor will be less because by submitting the prescriptions electronically (e-scripts) there is no question about what was written versus the typed prescription which they call e-scripts. HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples. Not only will it help by reducing prescription error it will also help promote legible and complete documentation. By using stream lined coding and billing it will increase the accuracy in the file so any staff member can easily access the records and know what is going on. Utilizing the electronic health record will allow the office to reduce the paperwork which will lead to staff efficiency and allow the physicians to meet their business goals while improving productivity and work life balance.
Forms in Electronic Health Records
One of the most important forms in an electronic health record, in my opinion is the physical exam. The physical exam keeps detailed records of all exams so that future visits show documentation of previous issues. It also allows other physicians to know of a patient’s issues in case of an accident.
The second important form is consent forms and authorizations that go hand in hand, without these forms certain procedures could not be completed and it also stops the wrong procedures from being performed. HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples.
The third form is medication list, without knowing current medications that a patient is taking the physician may not be able to treat the patient properly and may make a mistake that can cost the patient their life.
The fourth form is a surgery report, without having a surgery report that notes any organ that may have been removed or been modified a physician may give a wrong diagnosis and cause the wrong treatment for the patient. HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples.
Having an electronic health record helps to improve patient care and increase the amount of patients we have. Having an electronic medical record system, we can access our patient’s information at a click of a button. This can immensely help us to improve our care for our patients and improve on health diagnostics. Having an electronic health record will also help reduce the cost of care by not having to have the patient filling out redundant paperwork as it will already be stored in their electronic health record, when the patient comes in for a visit. It will allow for quicker patient information from other practices or if the patient has been in the hospital recently. There is the convenience of being able to send a patient’s prescription electronically to a pharmacy. Doing this electronically means that there is less paper work that is being used and it makes it easier for the pharmacy to process the prescriptions. HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples. According to healthit.gov (march 19,2014), With electronic Health Records, providers can give the best possible care, at the point of care. This can lead to a better patient experience and, most importantly, better patient outcomes.
Healthit.gov (march 19, 2014). Retrieved from http://www.healthit.gov/providers-professional/health-care-quality-convienance HCIS/140 Fundamentals of Electronic Healthcare Records – EHR Proposal Summary Essay examples
EHR Proposal Summary sample 2
The transition to electronic health records has had an impact on the healthcare industry with positive and negative implications. Some of these implications include concerns about lack of standards, security issues, and cost; however, the HL7 (Health Level 7), an international nonprofit standards-developing organization (SDO), has developed electronic standards to ensure that the components of an electronic health record can communicate more easily. In addition, electronic health record systems can be used to help improve patient health, the quality of care, and patient safety by providing access to complete, up-to-date records of past and present conditions.
The Institute of Medicine of the National Academies has put forth a set of eight core functions that an electronic health record should be capable of performing. These core functions are health information and data, result management, order management, decision support, electronic communication and connectivity, patient support, administrative processes and reporting, and reporting and population health. These functions are used to serve as the principal communication documents among various providers who may care for patients at different times in different departments; to provide the basis for all billing and reimbursement of services provided to patients; as legal documents which may become evidence in a court of law; to provide the basis for improvements in health; by public health departments, Homeland Security, and law enforcement officials to retrieve information from; by researchers to retrieve data from clinical trials to monitor the effectiveness and safety of new drugs; and by researchers to analyze de-identified data to find health trends in our society and measure which treatments seem to have the best outcomes.
The advantages of using electronic health records include health maintenance, trend analysis, alerts, and decision support. Health maintenance improves patient health through prevention and disease management. Trend analysis presents test results, vital signs, or other electronic health record data from several dates in a side-by-side comparison or graph that allows the clinician to spot trends in the patient’s health record. Alerts are messages or reminders that are automatically generated by the electronic health record to make the provider aware of a special situation. Decision support refers to the ability of electronic health record systems to quickly access evidence-based information relevant to the findings of the current case.
Forms used in the electronic health record display a desired group of findings in a presentation that allows for quick entry of not only positive and negative findings but entry details, such as value or result. An electronic health record accumulates patient health records in a computer database which can be accessed by healthcare professionals in a healthcare institution. “Patient health record data consists of administrative and demographic data and clinical data” (Gartee, 2011). The administrative and demographic data encompasses registration information provided by the patient or relative and certain legal documents that must be signed by the patient or his or her representative. This data includes HIPAA consent to use and disclose PHI, consent to treatment, Medicare patient rights statement, assignment of benefits, and disclosure records. The purpose for the HIPAA consent to use and disclose PHI form is for the patient to acknowledge receipt of the Notice of Privacy Practices. The purpose of the consent to treatment form is for the patient to give general consent to be treated by the healthcare practice or facility which is usually included in the registration form. The purpose for the Medicare patient rights statement is the Centers for Medicare and Medicaid require that patients be given a statement of their rights under Medicare, and the patient will sign an acknowledgement that he or she received the statement and his or her rights have been explained. The purpose for the assignment of benefits form is in order for a healthcare facility to be reimbursed by Medicare and other insurance plans, the policy holder must sign a form permitting the plan to pay the provider directly. And, the purpose for the disclosure of records form is HIPAA requires any disclosure of PHI for purposes other than treatment, payment, or operations of the facility to be tracked and recorded. Usually, patients are asked to complete demographic data on paper-based forms, and the data is transferred into the computer by the registration clerk; however, the forms may be scanned into a document image system through and electronic system. Clinical data include documents produced by the patient and healthcare professionals. Some standard types of clinical documentation include medical history, physical exam, diagnostic and therapeutic orders and reports, diagnostic images, nursing notes, referral consults, case management, problem lists, medication lists, and public health records.
I would strongly suggest we utilize electronic health records to store our patients’ information because we would benefit from the eight core functions of the electronic health record; using electronic health records for health maintenance, trend analyses, alerts, and decision support; and using forms to display a desired group of findings.
Gartee, R. (2011). Health information technology and management. Upper Saddle River, NJ: Pearson