The medical record serves several important purposes. It is the basis for the physician’s patient care planning and for continuity in evaluating the patient’s condition and treatment. In medical‚ record the evidence of the patient’s information about medical evaluation‚ treatment‚ and any change in condition and demographics about the patient. Medical records are used to communication between the physician and any other health professionals as needed‚ and whosoever the physician is working with
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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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Summary of “ELECTRONIC MEDICAL RECORDS PRIVACY‚ CONFIDENTIALITY‚ LIABILITY” Varditer Avetisyan The main purpose of this article is to present the current controversy of utilizing electronic records (EMR) in place of paper records in today’s medical environment. Specifically‚ the article mentions the pros of an EMR as being; making it easier to share medical information‚ making access to medical records more fluid‚ and reducing the overall cost of care delivery. It also mentions the cons
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Documentation Requirements for the Acute Care Inpatient Record (AHIMA Practice Brief) The medical record is a tool for collecting‚ storing‚ and processing patient information. Records are being used daily for a multitude of purposes‚ including: • providing a means of communication between the physician and the other members of the healthcare team caring for the patient • providing a basis for evaluating the adequacy and appropriateness of care • providing data to substantiate insurance
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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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the organizational goals and objectives. Healthcare institutions encounter an increasing challenge in proper utilization of resources‚ improving care and lowering costs. The reduction of bottlenecks and the implementation of solutions that facilitate efficient elucidations to major challenges allow any business to prosper. However‚ in Long term acute care (LTAC) hospital facilities for seniors‚ the assertion is easier said than done. Successful action management is not a ‘one time’ event. Our Lady
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Introduction Medical record numbering and filing is the most important tasks in the management of medical information in health care institutions. Well kept and filed medical records enhance effective and efficient collecting‚ recording and retrieval of patient health information whenever required. The patient record care system adopted influence the ease of maintenance and retrieval of medical records. According to the Remote Health Branch of United States‚ health care institutions ought to
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personal health record‚ you are able to have your health history at the tips of your fingers at any one time. I read a story about the challenges of making sure doctors have all of the information that they need. Going to the doctor can be challenging when you don’t remember every medical concern or finding that has popped up in your life time. This gets even more difficult as you get older. Paper records are notoriously unhelpful when these situations pop up. Electronic health records can only do so
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Oftentimes‚ the complexity of a patient’s condition may not allow for discharge from an acute care setting to their prior place of residence. Instead‚ the patient may be deemed more suitable for continued care in a long-term acute care facility (LTAC). I had the opportunity to care for a patient who underwent a complex discharge process‚ as he required long-term mechanical ventilation. To fully understand the intricacy of his discharge‚ it is important to recognize pertinent assessment data‚ interdisciplinary
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