Reviewing Health Records
For this assignment I interviewed a doctor from Missouri named Dr. Clayton Whetmore. Dr. Whetmore currently works with EmCare, as an independent contractor, covering the Emergency Department at Samaritan Memorial Hospital in Missouri. Dr. Whetmore is also currently intimately involved in his hospital's transition from paper documentation to implementation and meaningful use of electronic health records.
Having recently transitioned from paper to electronic format, Dr. Whetmen’s facility uses McKesson, the company from which his hospital purchased healthcare information technology (HIT) and electronic health record (EHR) software. McKesson's Emergency Department software utilizes templates from the gold standard in paper documentation, the T System. Problem driven, a chart that is specific to the patient's presenting complaint is generated. This allows the physician to circle or line out relevant information that would be pertinent to most patients with that presentation. There is also room to enter further text. In other words, McKesson contracted with T-System to use their templates as electronic health records. Simply clicking once circles (a second click changes to backslash) the desired documentation on the electronic template. If someone should wish to view a patient’s health records a user name and password are required to access the computer. Another user name and password, unique to the person entering information, are then required to access the patient's record. Different personnel have permission to only access and/or modify the record, based on their particular job description. Besides identification data, all Medical Personnel (EMTs/Paramedics, Nurses, Physicians) who access the chart can enter Past Medical History, Past Surgical History, Medications, Allergies, Social History, as well as the Presenting Complaint and Vital Signs that were measured. The record reflects who entered/modified the information. To assure that the information is
Having recently transitioned from paper to electronic format, Dr. Whetmen’s facility uses McKesson, the company from which his hospital purchased healthcare information technology (HIT) and electronic health record (EHR) software. McKesson's Emergency Department software utilizes templates from the gold standard in paper documentation, the T System. Problem driven, a chart that is specific to the patient's presenting complaint is generated. This allows the physician to circle or line out relevant information that would be pertinent to most patients with that presentation. There is also room to enter further text. In other words, McKesson contracted with T-System to use their templates as electronic health records. Simply clicking once circles (a second click changes to backslash) the desired documentation on the electronic template. If someone should wish to view a patient’s health records a user name and password are required to access the computer. Another user name and password, unique to the person entering information, are then required to access the patient's record. Different personnel have permission to only access and/or modify the record, based on their particular job description. Besides identification data, all Medical Personnel (EMTs/Paramedics, Nurses, Physicians) who access the chart can enter Past Medical History, Past Surgical History, Medications, Allergies, Social History, as well as the Presenting Complaint and Vital Signs that were measured. The record reflects who entered/modified the information. To assure that the information is