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Health Records Structures

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Health Records Structures
Health record structures in computer driven formats have arrived on the health care scene. Computerized formats allow for efficiency and ease of retrieval, accessibility of data, storage, billing, and use of evidence based practice in patient care. Health records are more easily able to be shared among providers and across health care systems. Electronic medical records are instrumental in advancing the structure of health care records to the computer age. While the adoption of computerized systems has been slow, these formats are paving the way to improving management of patient care and day-to-day health care operations.
In the hospital setting computerized systems allow for organization of information and ease of access of information. Patient care related data can also be easily entered from any point within the system, efficiently and accurately.
The benefits of health record structures are numerous, including increased efficiency, reduction of medication and patient care errors, organization of information, and efficiency in clinical decision making. (Helton, 2012).
As with any system there are also negatives. Implementation costs related to the actual system as well as training, education and workflow redesign can be a concern especially when implementation costs may not be worth the benefit of the system.
Lack of standards can also be a negative impact as they are difficult to create leading to issues with maintenance of security of patient data and ensuring patient privacy.
Data collection and how the data will be utilized within the structure is a big consideration when implementing system of this type as well. During the course of this presentation, we discuss how health record structure's capture data and evaluate it’s effectiveness. In addition, we will look at how record structures in their current state as well as evolution of the system will impact the delivery of health care, the implications managing privacy and security

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