Nur 3062 chapter 5

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Nur 3062 chapter 5

  1. 1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 5 Electronic Health Records
  2. 2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Evolution of Electronic Health Records Terms used to describe automated records • Computerized medical record • Computer-based patient record • Electronic medical record • Electronic health record
  3. 3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Longitudinal Patient Record A longitudinal patient record contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient’s health care encounters.
  4. 4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advantages of Manual Records • Low start-up costs • Training of staff is simple • Requires less technically trained staff • Available because there is no downtime
  5. 5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Disadvantages of Manual Records • Retrieval is not easily customized. • Hand-written information can be difficult to read. • Difficult to abstract information • Undocumented services are not easily discovered until discharge analysis occurs.
  6. 6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advantages of Automated Records • Improves access to patient information • Multiple users can access patient information simultaneously and remotely • Eliminates paper record storage • Improves readability • Timely capture of data
  7. 7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advantages of Automated Records (Continued) • Views can be customized • Updates occur easily • Customized retrieval of information • Enhanced security • Reduction in administrative costs
  8. 8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Disadvantages of Automated Records • Increased start-up costs • Selection and development is time consuming. • Staff training is time consuming. • Staff training can be costly. • Technical staff is needed. • User resistance can occur.
  9. 9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transition to Electronic Records • Scanning of documents • Hybrid records • Record transitional template
  10. 10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Regional Health Information Organization (RHIO) A RHIO is an electronic network of patient medical information gathered from multiple health care organizations in a geographic region.
  11. 11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Stakeholders in a RHIO • Hospitals • Physicians • Patients • Health plans and insurers • Public/governmental health agencies
  12. 12. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. American Recovery Reinvestment Act Areas that the act will impact include: • Incentives for adoption of EHRs • Advancement of Health Information Exchange • New privacy regulations • HIM workforce opportunities
  13. 13. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Components of Electronic Health Records • Characters • Fields • Records • Files • Data • Information
  14. 14. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Registration Screen
  15. 15. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Administrative and Clinical Applications • Registration-admission-discharge-transfer system (RADT) • Clinical applications – Patient monitoring systems – Pharmacy – Laboratory – Radiology – Nursing – Medical documentation
  16. 16. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Registration Demographic Information
  17. 17. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Clinical Information: Patient History
  18. 18. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Intake Screen at Exam
  19. 19. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transitioning to Electronic Records • Many challenges will have to be met. • Health information professionals must have an understanding of automated systems. • Transitions to EHRs can take years. • Facilities need to establish and develop implementation plans.

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