computerized medical record and billing system introduction

Topics: Medical record, Electronic medical record, Health care Pages: 2 (446 words) Published: December 1, 2013

The information contained in the medical record allows nurses and doctors to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. By making a computerized system for a medical record, nurses and doctors can easily determine if the patients has already have a record into that hospital . We are proposing a computerized medical system to lessen the work of those assistant desk secretary . The modern hospital is a storehouse of technology and training unmatched in human society. These lifesaving institutions are often the biggest employer in town, making them - justifiably - the pride of their communities. An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.

Benefits of Electronic Medical Records
An EMR is more beneficial than paper records because it allows providers to:

Track data over time
Identify patients who are due for preventive visits and screenings Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings Improve overall quality of care in a practice

The information stored in EMRs is not easily shared with providers outside of a practice. A patient’s record might even have to be printed...
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