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 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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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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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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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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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
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Paper-Based Versus Electronic Medical Record Keeping For many years‚ physicians’ offices documented all data in paper-based medical charts. Now‚ the physician or clinician records the medical data into a computer. Information stored in this manner is known as an electronic-based medical record or EMR. By definition‚ an EMR is a computerized record of the important health information regarding a patient including the care of that individual and the progress of that patient’s condition
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Electronic Health Records The electronic health records fits seamlessly with a central cost-saving of health care reform: to shift U.S. health care from an expensive‚ pay-per-service system based on quantity to one that emphasizes quality. The goal now is to have medical payments reward good care -- in a way that’s difficult to do with paper records. "You really can’t have accountable care without electronic records‚" says Judy Hanover‚ a research director for IDC Health Insights‚ a health care
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1. Explain how an organization can ensure the quality of data contained in its electronic health record (EHR) information system. (20 points) Electronic documentation tools offer many features designed to increase both the quality and the utility of clinical documentation‚ enhancing communication between all healthcare providers. Silow-Carroll‚ S.‚ Edwards‚ J.‚ Rodin‚ D.‚ (2012)‚ stated that one of the key driver in the implementation of EHR is to improve health care quality‚ and patient safety
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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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