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
Premium Medicine Medical history Pneumonia
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
Premium Patient Physician Medicine
1. My favorite sport is football‚ the proper one‚ the one that Americans call ’Soccer’. Here is a game played by two teams of 11‚ each trying to pit their wits and skill against the other in an attempt to win the match. The game lasts for 90 minutes in two halves of 45 minutes each. The reason for this is so that each team plays in both directions so that no team has an unfair advantage with slope or wind which could affect the game. The reason I like it so much is that‚ as a small boy‚ I was
Premium Skill Learning Game
Albert Einstein said‚ “Learning is not a product of schooling but the lifelong attempt to acquire it.” 2. Penn Foster is one route that helps motivated independent learners acquire the knowledge and certification they need. 3. Students’ lives may change due to the decision to further their education. 4. I plan to use the following method balance work‚ family‚ and Penn Foster. II. Step 1: Figure Out What Really Matters in Life 1. Spending introspective time thinking about
Premium Albert Einstein Debut albums Business
ELECTRONIC RECORD The Health Information Technology for Economic and Clinical Health Act also known as the HITECH Act is part of the American Recovery and Reinvestment Act of 2009 (ARRA) which contains incentives related to health care information technology in general and contains specific incentives designed to accelerate the adoption of electronic health record (EHR) systems among providers. Because this legislation anticipates a massive expansion in the
Premium Electronic health record Electronic medical record Health care
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
Premium Electronic health record Health care
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
Premium Electronic health record Medicine Health informatics
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
Premium Electronic medical record Health care Medicine
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
Premium Electronic health record Patient Health care
Electronic Health Record System Conversion! Health Info Fundamentals Practicum After decades of paper based medical records‚ a new type of record keeping has surfaced Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of
Premium Electronic health record Health informatics Health care