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isaac331994

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14y ago

how will conversion of the patient records to electronic format impact patient care?

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Q: Patient records to electronic format impact patient care?
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What does EMR stand for?

The EMR (electronic medical record) is used to capture and manage patient data. Unlike the CPR (computerized patient record), information in an EMR is acquired in electronic format, rather being scanned in from paper-based records. An EMR includes the results of a PACS system (images and reports) and other information such as lab results, latest vaccinations, and so on. Compare with EHR (electronic health record).


Which records are stored in a format that only a computer can process?

Electronic records


The Advantages and Disadvantages of Electronic Medical Records?

Recent technological advances have made it possible for each major hospital, clinic or doctor’s office to have their own, stand-alone, electronic medical records that summarize each individual patient’s medical history. In most states in the USA, a medical office, by law, has to retain each patient’s medical records for at least seven (7) years. The ability to store medical records in an electronic format has great advantages over storing them in paper format, and both space and money can be saved by choosing to store records electronically. It is also far easier to update a patient’s medical records if they are stored in an environment where anyone who needs to can access them at the touch of a button. When records are computerized, they are also standardized, and gone are the days when new doctors or nurses cannot read older physician’s handwriting or understand their abbreviations. Electronic medical records include not only questionnaires completed by the patient and his attending physicians but also all types of ancillary medical documentation like X-rays, ultrasound images and MRI images. Also, despite the fact that these records are stored by the hospital, clinic or doctor’s office, ownership still vests with the patient himself, and copies of the records must be made available to him whenever he requests them. One of the few disadvantages to having a patient’s medical records stored in electronic format is that inappropriate people may be able to access private and confidential records. Within the standard hospital hierarchy, numerous healthcare professionals at every level have to access a patient’s records - from his physicians right down to the medical billing clerks - and care must be taken so that those without the necessary clearance are not able to access sensitive information. In the USA, medical privacy is legislated, and codes like the Health Insurance Portability and Accountability Act lay down what can and can’t be done with medical records. Although it is presently practically possible for all hospitals and other healthcare facilities to utilize electronic medical records, not all facilities have opted to implement the required IT systems, and it will still take quite some time before all institutions become paperless.


Who has ownership of health care records?

The physician keeps health records, safely, maintained in the Electronic Health Records (EHR). The record is stored in a digitized format. However, the patients have complete rights to view their health records by using patient portals whenever the want.


The Increased Usage of Electronic Health Records?

Electronic health records are being used more and more as the technology continues to improve. The benefits of electronic health records far outweigh the cost and time it takes to transfer old files into the new format. Many hospitals are currently undergoing the process of creating digital files for all of their patients. The Difficulty of Conversion The amount of paper that is stored with patient information in any given hospital is overwhelming. Though most doctors and medical administrators agree that electronic health records would improve their ability to serve patients, the daunting task of scanning documents into the computer system has held most hospitals back from the conversion process. Recent upgrades in scanning equipment have helped to speed up the process, however, and many institutions are beginning to implement digital files as a regular part of their operations. As technology improves, the number of electronic health records will continue to increase. Instant Updates Once a medical institution is completely working form electronic health records, doctors and nurses can communicate about patients instantaneously. Doctors will carry laptop computers that are tied into the health records of the hospital, and they will make changes to their orders as they stand in a patient’s room. There is no chance for a time lag between a doctor’s changed orders and a nurse receiving the changes. Everything is transmitted automatically to anyone who has access to the records anywhere in the hospital. Doctors also have instant access to any previous notes they have made about a patient, or notes from nurses who have worked with the patient. Better Accuracy The ability of doctors and nurses to immediately change information about any patient who has electronic health records greatly reduces the possibility of mistakes in treatment. The doctor has immediate access to a patient’s entire file at the click of a button, so he or she is always fully informed on every aspect of treatment and symptoms. Since the information is changed universally throughout the system, the chance that someone will miss a change and give the patient an incorrect dosage or treatment is also greatly reduced. Electronic health records will revolutionize the effectiveness and efficiency of medicine.


When should a patent be advised of the existence of computerized databases containing medical information about the patient?

On AMA the patient and physician should be advised about the existence of computerized data both before and information is stored.


Does Patient have rights to their medical records?

Of course. Patients have complete right to accessing their medical records. Even more so with the 2014 ONC criteria for Electronic Health Records (EHR) and Meaningful Use Stage 2 where physicians have to ensure that at least 5% of their total registered patients access their medical data from their patient portals. While the usage of patient portals was not so common earlier, because of limited functionality, they have been continuously worked upon by healthcare organizations and are now much more usable. Patients can now see their Summaries of Care thanks to the universal CCD/CCR format which also allows patients to View, Download and Transfer their care summaries to any other physician they choose to. This is something truly revolutionary and will not only give patients more access to their medical records but also make them more engaged in their care.


Which health record format is most commonly used by healthcare settings as they transition to electronic records?

Hybrid


What file format does electronic records management work with?

Records management is used according to the value of the records rather than their physical format. More or less it will work with most formats, however from time to time you can experience issues especially if the records you preserve do not have a physical existance.


What is the most common format for the Blue Cross Blue Shield identification number?

the id number of the patient


What are manual files?

Manual files are records that are not entered or stored in electronic format. These are physical documents which are created and saved manually.


A patient calls the pharmacy and asks if it's safe to take a certain drug while nursing you oull the package insert and see that it's the older format what section do you need to look in?

If a patient calls the pharmacy and asks if it's safe to take a certain drug, and when you pulled the package insert, you discovered that it was the older format, simply check out the Dosage and Administration section.