Health record structures in computer driven formats have arrived on the health care scene. Computerized formats allow for efficiency and ease of retrieval, accessibility of data, storage, billing, and use of evidence based practice in patient care. Health records are more easily able to be shared among providers and across health care systems. Electronic medical records are instrumental in advancing the structure of health care records to the computer age. While the adoption of computerized systems has been slow, these formats are paving the way to improving management of patient care and day-to-day health care operations. In the hospital setting computerized systems allow for organization of information and ease of access of information. Patient care related data can also be easily entered from any point within the system, efficiently and accurately. The benefits of health record structures are numerous, including increased efficiency, reduction of medication and patient care errors, organization of information, and efficiency in clinical decision making. (Helton, 2012). As with any system there are also negatives. Implementation costs related to the actual system as well as training, education and workflow redesign can be a concern especially when implementation costs may not be worth the benefit of the system. Lack of standards can also be a negative impact as they are difficult to create leading to issues with maintenance of security of patient data and ensuring patient privacy. Data collection and how the data will be utilized within the structure is a big consideration when implementing system of this type as well. During the course of this presentation, we discuss how health record structure's capture data and evaluate it’s effectiveness. In addition, we will look at how record structures in their current state as well as evolution of the system will impact the delivery of health care, the implications managing privacy and security of the data, training, maintenance components and how the structures effectiveness can be evaluated.
Health care in the United States is known to rapidly advance and change. Compared to other industries however, it lags in adopting and incorporating information technologies ( Goldschmidt, 2005). Patients today demand and expect quality health care that is safe and effective. Health care systems are responding by implementing technologies such as health records structures that improve upon health care delivery by incorporating consistency, safety, and use of evidenced based practice in clinical and care decisions (Jamal, McKenzie & Clark, 2009). Health record structure use has demonstrated effectiveness in reducing and preventing medical errors and increasing patient safety. Record structures use data and received information to coordinate patient care and for such activities as medication Computerized health records increase patient safety as they have the ability to enforce provider use of evidence based guidelines and practices in care. Most evidenced based guidelines can be built into systems are available at the point of contact with the patient. Accessibility of guidelines, improves clinical decisions as data is structured and the guidelines are tools to support decision making. In addition, they allow for a more accurate collection and use of clinical data that can follow the patient and be shared amongst providers across the continuum of care. The health record structure can easily sort and store the information for use by the provider to make health care decisions (Goldschmidt, 2005). Computerized order entry has also reduced the incidence of medical errors by eliminating the issue of poor hand writing and having to decipher notes and orders. Record structures impact health care costs when implemented. Reduction of costly medical errors is one way. Another is in the efficiency and effectiveness of coding and billing for services...
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