Chapter 3 – Medical Record | History of Present Illness | Patient is a 35 year old male complaining of nausea‚ pyrosis‚ indigestion‚ and melena stool. Patient stated that he has been experiencing abdominal pain that wakes him in the middle of night for over a month. He stated that he normally can drink a glass of milk or baking soda water to relive the pain‚ but this has no longer been effective. | Past Medical History | Patient is a smoker who drinks daily and suffering from obesity.
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A Deeper Look into Today’s Electronic Health Record Alexandria Carroll Hodges University HIM 2501 Professor Shelye Mishler March 25‚ 2013 In the healthcare arena‚ information is everywhere and it is accessed and utilized by everyone. Information is the lifeblood of any organization and no organization would exist without it (Phillips‚ 2005). Regardless if the information is in paper form or accessed through a computer‚ there is a process needed to locate‚ retrieve‚ and evaluate
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1. Explain how an organization can ensure the quality of data contained in its electronic health record (EHR) information system. (20 points) Electronic documentation tools offer many features designed to increase both the quality and the utility of clinical documentation‚ enhancing communication between all healthcare providers. Silow-Carroll‚ S.‚ Edwards‚ J.‚ Rodin‚ D.‚ (2012)‚ stated that one of the key driver in the implementation of EHR is to improve health care quality‚ and patient safety
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Electronic Medical Records and Confidentiality Issues Abstract Electronic Medical Records save health care facilities thousands of dollars every year‚ and this accounts for the cost of the electronic system itself! Major disasters such as Hurricane Katrina in New Orleans Louisiana‚ showcase the benefits of the electronic medical record system. Electronic medical records are stored throughout the country so that if a tragic/unplanned event occurred‚ it won’t destroy the health care
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The Effect of the Health Insurance Portability and Accountability Act on the Privacy of Electronic Medical Records The past decade has encountered a strong push for medical providers across the United States to adapt to a universal electronic medical record system. Throughout this essay‚ we will discuss the effect of the Health Insurance Portability and Accountability Act on the privacy of patient electronic medical records. This article discusses the failures and successes of HIPAA‚ including
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A Study of Electronic Records Management in the Namibian Public Service in the Context of E-Government In striving to achieve good governance‚ organizations including Governments worldwide have been turning to information technologies. The conduct of business online has led to an increase in the creation of electronic records‚ which has brought about challenges in the management of records. This study‚ titled “A Study of Electronic Records Management in the Namibian Public Service in the Context
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Communication refers to the degree to which the patient heard‚ kept informed through understandable terms‚ afforded social interaction‚ and time during consultation and provided psychological and non-technical information (Tucker‚ 2002). If communication is good‚ which includes information from the service provider to the patient on the type of care he or she will receive‚ uncertainty is alleviated that will increase the patient’s awareness and sensitivity of what to expect‚ then patient satisfaction
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How does effective communication incorporate the basic elements of communication? Health communication means from the way we socialize about our health problems around the dinner table to the patient-caregiver reciprocal action‚ good leadership and great teamwork in health care organizations‚ and the health images in the media. Because our health is so dynamic‚ complex‚ and mutually dependent‚ while it is very important to understand the current issues and how the many constituent element‚ as of
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Implementing Electronic Health Records Health Care Information Systems HCS 483 August 17‚ 2013 Implementing Electronic Health Records In the move toward electronic health records for patient’s there are obstacles that have to be addressed‚ procedures implemented into the process‚ and security maintained at the highest level. Electronic Health Records Electronic health records (EHR) are often confused in terminology with electronic medical records and the two are vastly different with
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America’s current medical recordkeeping system? How would electronic medical records alleviate these problems? The majority of America’s current medical record keeping is paper based which creates a lot of problems like:- a. Recordkeeping became really difficult with growing numbers of patients and their visits to Medical Practitioner. There are shelves full of folders and papers in corridors. b. It makes it difficult to effective communication‚ referring and access to the records. During emergency
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