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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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
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Related Studies 3.1.1 A Study of Electronic Records Management in the Namibian Public Service in the Context of E-Government In striving to achieve good governance‚ organizations including Governments worldwide have been turning to information technologies. The conduct of business online has led to an increase in the creation of electronic records‚ which has brought about challenges in the management of records. This study‚ titled “A Study of Electronic Records Management in the Namibian Public
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Electronic Health Record Savannah Tapp-Crump RN Oklahoma Wesleyan University Electronic Health Record The electronic health record also known as the EHR‚ has transformed the world of health care and documentation as we know it. An electronic health record is a “ computer-based data warehouse or repository of information regarding the health status of a client‚ which is replacing the former paper-based medical record; it is the systematic documentation of a client’s health status
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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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Over the past five decades healthcare record keeping has been evolving. In order to protect patient ’s records and encourage healthcare providers to keep up with current technology trends several federal agencies have been developed. As a result of these agency formations several laws and regulations have been put into place. The development of healthcare information technology (HIT)‚ and subsequently the rules and regulations‚ began to evolve in the 1960 ’s with the development of Medicare and
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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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Electronic Health Record (EHR) System Potential threats and measures taken to protect it Since the early 1980s‚ information technology have improved and revolutionized every aspect of our lives. We use information technology to do our daily chores like shopping and reading the latest global news at the comfort of our living room. It replaces old challenges with new possibilities. However‚ one of the areas that had evolved to this new demand in information technology but rather in a slow phase
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Electronic Medical Records- Reduce Errors and Increase Efficiency with EMR Software Errors in the healthcare industry can literally cost someone his or her life‚ not to mention open the door for an unending mountain of lawsuits. In order to reduce the chances of this happening‚ your healthcare organization must be proactive about increasing efficiency‚ and reducing errors. These are two common problems that plague the healthcare industry. With electronic medical records you can significantly reduce
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An Electronic Document and Records System (EDRS) is a computer program (or set of programs) used to track and store records. The term is distinguished from imaging and document management systems that specialize in paper capture and document management respectively. ERS systems commonly provide specialized security and auditing functionality tailored to the needs of records managers. The National Archives and Records Administration (NARA) has endorsed the U.S. Department of Defense standard 5015
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