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 being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital signs, medical history, immunizations, laboratory data, radiology reports and billing information. The EHR’s purpose can be understood as a complete record of patient encounters that automates access to information and has the potential to streamline the clinician's workflow in a healthcare setting. Electronic health record has the potential to strengthen the quality of care and the relationship between clinicians and patients through ready access to accurate and up-to-date patient information from office or remote locations.
Moving into an electronic health record system could seem to be much for a facility that has being paper based for years. Now the implementation phase will begin. Any change involving a quality improvement program is a major undertaking. The organizations’ culture will determine how decisions will get made and work will get done. Success is usually greatest when there is a willingness to learn and a willingness to adapt to a new process. Finding the right system for the facility is a must. On the administrative side, the development of practice management programs and electronic health records streamline