Electronic Records Langemo (1995) describe records as the memory of the organization‚ the raw material for decision making‚ and the basic for legal defensibility. Meanwhile Gagnon (1987) defines records from the functional standpoint when he says all recorded information regardless of media or characteristic‚ made or received and maintained by an organization or institution in pursuance of its legal obligations or in the transaction of business. However‚ Clubb (1991) admits that it was relatively
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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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Abstract Electronic health records (EHR) is more and more being utilized in organizations offering healthcare to enhance the quality and safety of care. Understanding the advantages and disadvantaging of EHR is essential in the nursing profession as nurses would learn its strengths and weaknesses. This would help the nursing profession know how to deal with the weak areas of the system. The topic on advantages and disadvantages of EHR has been widely researched on with different researchers coming
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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
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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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050-word paper about a communication modality used in health care. Include the following in your paper: · Identify one specific mode of communication used by consumers and health care providers‚ such as e-mail‚ a web-based forum‚ or electronic medical records. · List and discuss the following: o One benefit to the patient o One aspect relating to the values and importance of maintaining patient confidentiality when using this mode of communication o One reason this mode
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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
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Kaplan University Going Paperless: Electronic Medical Records versus Paper Medical Records “Is it time to make the switch?” Carletta Howard Kaplan University Abstract Making the switch to an electronic medical records system will help to bring forth health care advances with the systems data quality and availability. This research study uses focus groups and surveys to get the opinions of different health care providers and some patients on what they think EMR will do for the health care
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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
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The similarities that I found for the organizations of patient files are that most of the paper files between the small and medium facilities are handled the same way. With the demographics and administrative filed on the left and medical on the right. Such as reports of labs‚ patient progress notes‚ prescription documentation‚ and any miscellaneous reports. Some of the small and medium facilities seem to use this filing method. This filing works well in a small to medium facility because there are
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