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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Running head: INFORMATICS NEEDS ASSESSMENT 1 Informatics Needs Assessment for Implementation of Electronic Health Records Cathleen Wallace University of Phoenix HCS/482 John PI‚ MBA January 2‚ 2015 Informatics Needs Assessment for Implementation of Electronic Health Records Implementing a new electronic health records (EHR) system to replace manual records is an extremely complicated task. EHRs use complex algorithms to exchange patient data among different physicians and departments
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MIBC 101 Unit 2 Assignment 1. Explain the difference between the hybrid medical record and the EHR. hybrid record A record in which both electronic and paper media are used. electronic health record (EHR) A secure real-time‚ point-of-care‚ patient centric information resource for clinicians allowing access to patient information when and where needed and incorporating evidence-based decision support. (Davis 67-68) 2. List the features of an EHR. Explain how these features are advantageous
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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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Qualitative medical record analysis is a review of medical record entries for inconsistencies & omissions which may signify that the medical record is inaccurate or incomplete. Such an analysis requires knowledge of medical terminology‚ anatomy & physiology‚ fundamentals of disease processes‚ medical record content‚ & the standards of licensing‚ accrediting‚ & certifying agencies. It is usually performed by a qualified medical record practitioner. Quantitative medical record analysis is a review
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Terrice c. cistrunk 109 Locksley WY. #64 Student# 21229727 Exam# 40976500 Part A. 1. The difference between qualitative and quantitative medical record analysis is. Qualitative analysis involves review of document quality based on regulatory and clinical standards. As where quantitative analysis is done to determine if the necessary documents and forms are present‚ complete and authenticated. 2. The basic specifications for designing a form are. That the form should be designed
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Electronic Health Records: The Role of Electronic Health Records and Health Information Exchange in the Delivery of Quality Healthcare R Arku Community College of Allegheny County Health Information Technology‚ Cohort 5 Tutor January 14‚2011 Contents Abstract 3 Introduction 4 Quality Definition 6 Data Collection Challenges 7 Electronic Records and its influence on quality 9 Data Infrastructure – Performance Measurement Foundation 11 Quality Measurements and Data Extraction
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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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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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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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