Chapter 3 – Medical Record History of Present Illness The patient is a 61 year old female. The patient is complaining that they feel weak‚ their urine is dark‚ nausea‚ pain in the abdomen. Past Medical History Mrs. Carter has suffered from seizures since she was 14 years old. She has been taking Dilantin to help keep her seizures under control and to a minimum. Clear history otherwise. Physical Examination Temperature was 99.8 Pulse was 83 Blood Pressure was 120/84 Abdomen area was swollen
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Electronic Medical Records Progress into the future Melissa D Pipes‚ RN Benefits to Nursing Staff ● Easier charting‚ more detailed choices resulting in more in depth physical assessment documentation. Immediate tallying of intake and output ratios‚ potentially averting a negative patient outcome. ● Benefits continued... ● ● Timely charting resulting in less overtime. The ability to chart at bedside‚ allowing more contact with the patient. Test results readily available from
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Gone are the days when all medical documentation was done using a pen and paper. Thanks to advancements in technology‚ there are modernized ways to gather‚ store‚ and transmit information more efficiently. The paper charting method has been shifted to a rather digital version of documentation known as the Electronic Health Record (EHR). The EHR provides a real-time and secure way to manage patient medical records. “Included in this information are patient demographics‚ progress notes‚ problems‚ medications
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Electronic Health Records: The Role of Electronic Health Records and Health Information Exchange in the Delivery of Quality Healthcare R Arku Community College of Allegheny County Health Information Technology‚ Cohort 5 Tutor January 14‚2011 Contents Abstract 3 Introduction 4 Quality Definition 6 Data Collection Challenges 7 Electronic Records and its influence on quality 9 Data Infrastructure – Performance Measurement Foundation 11 Quality Measurements and Data Extraction
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MIBC 101 Unit 2 Assignment 1. Explain the difference between the hybrid medical record and the EHR. hybrid record A record in which both electronic and paper media are used. electronic health record (EHR) A secure real-time‚ point-of-care‚ patient centric information resource for clinicians allowing access to patient information when and where needed and incorporating evidence-based decision support. (Davis 67-68) 2. List the features of an EHR. Explain how these features are advantageous
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Running head: INFORMATICS NEEDS ASSESSMENT 1 Informatics Needs Assessment for Implementation of Electronic Health Records Cathleen Wallace University of Phoenix HCS/482 John PI‚ MBA January 2‚ 2015 Informatics Needs Assessment for Implementation of Electronic Health Records Implementing a new electronic health records (EHR) system to replace manual records is an extremely complicated task. EHRs use complex algorithms to exchange patient data among different physicians and departments
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Running head: ELECTRONIC HEALTH RECORDS The Advantages and Disadvantages of Electronic Health Records Michelle H Gay Cabarrus College of Health Sciences Abstract There are many advantages to electronic health records but there are as many disadvantages to implementation of this technology. This paper will discuss the advantages and disadvantages that take place during the implementation process of electronic health records. This material was gathered from published materials. The health
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Unit 9 Final Project HS499-01 January 15‚ 2012 Professor Kristen Hathcock Kaplan University Going Paperless: Electronic Medical Records versus Paper Medical Records “Is it time to make the switch?” Carletta Howard Kaplan University Abstract Making the switch to an electronic medical records system will help to bring forth health care advances with the systems data quality and availability. This research study uses focus groups and surveys to get the opinions of different health care
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Historically‚ the only means available to record health information were paper and pen‚ today the industry has multiple options. This type of information has been known to be transmitted between practitioners and facilities via personal messenger‚ phone‚ or interdepartmental mail. There are numerous options of transmittal but most of the above mentioned methods were fraught with errors and time consuming. Medical information recorded in paper format makes tasks difficult‚ provides opportunities
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review: The Adoption of Electronic Health Records. The implementation of electronic health records (EHR) in the healthcare industry has been an evolving concept throughout the healthcare ecosystem for some time. The term EHR is often used interchangeably with EPR (electronic patient record) and EMR (electronic medical record). Even though the terms are mostly used to describe the same thing‚ the differences between them can be defined. EMR is defined as the patient record created in hospitals and
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