I have seen a change in medical record keeping since I started more than 15 years ago. Every patient would have a paper chart. This would include there personal information, which included social security number and medical history. Physicians would document there progress notes and any orders for tests or medications. The nurses would document when they gave medication to there patients. This process was very time consuming and sometimes very hard to read. With electronic medical records this process has become much easier on the physicians and nurses. Especially for nurses because now they can read what the physicians are ordering. There are touch screens that make ordering medications easier, faster and accurate. If the medication is not in the patients chart the nurse can not order it. When insurance companies request medical records instance of mailing the records which can take several days, now these records can be electronically done. The disadvantages is if the computer system goes down than the nurses can not see patient’s records and it makes it difficult to treat patients. Depending on your positions records are available on a need to know bases. Implementing a universal electronic medical record in the hospital or physician setting can be very difficult. The cost is very expensive and keeping patient records safe. With so many viruses and hackers in the world security is the most important in electronic medical records. I believe electronic medical records is the way to go, with proper training and better security this process will continue to become the wave of the future.
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