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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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 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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student will discuss the national mandate of electronic health records (EHR)‚ and how this mandate is being implemented at the Cleveland Clinic Foundation. Also discussed are how Cleveland Clinic is progressing to achieve EHR‚ and what challenges this brings to patient confidentiality and self-determination. Lastly this student will provide information on the benefits of EHR in healthcare. According to Gunter & Terry (2005)‚ “The electronic health record (EHR) is an evolving concept defined as a
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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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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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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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Kaplan University Going Paperless: Electronic Medical Records versus Paper Medical Records “Is it time to make the switch?” Carletta Howard Kaplan University Abstract Making the switch to an electronic medical records system will help to bring forth health care advances with the systems data quality and availability. This research study uses focus groups and surveys to get the opinions of different health care providers and some patients on what they think EMR will do for the health care
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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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Running head: ELECTRONIC HEALTH RECORDS The Advantages and Disadvantages of Electronic Health Records Michelle H Gay Cabarrus College of Health Sciences Abstract There are many advantages to electronic health records but there are as many disadvantages to implementation of this technology. This paper will discuss the advantages and disadvantages that take place during the implementation process of electronic health records. This material was gathered from published materials. The health
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