...TYPES OF HEALTH RECORDS Types of health Records Andre Cornwall Westwood College TYPES OF HEALTH RECORDS Types of Health Records There are all types of Health Records documentation available; it may be paper or electronic. The first type of documentation is Acute Care. Acute Care is the foundation for content and practices for other healthcare settings, like Clinical Data, Administrative Data, Consents, Authorizations, and Acknowledgments. Next is Specialized Health Records like Emergency Care, Ambulatory Care, Ambulatory Surgical Care, Long-term Care, Hospice Care, Behavioral Healthcare, and Rehabilitation Services Documentation. Paper or Plastic? That is what the grocery store would ask you, but the times are changing and so is the Healthcare field. Now you do not have the choice in how your information is documented in the Medical Record. There are still paper records but workers of the Health field find them self-scanning paper information into the EHR’s system. Let’s describe the different documentation, may it be paper or electronic. Clinical Data is all the information one will get for a patient when they are admitted to the hospital. While the patient is admitted other info will be add to the patients chart: * A patient’s medical history, like the Chief complaint, Present illness, and Review of systems. * The reports of consulting physicians which is the opinion of another physician. What I call “Get a second opinion”. * A discharge summary...
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...Organizational Change Plan Part 1 The healthcare industry has to be up to date in the most technologically advanced way possible in order to provide the best care to the patients. Even though most people expect their health information to be recorded during their doctor or hospital visit, they do not realize that using the old pen and paper method is outdated, and not the best possible way to record information. In this paper, the author will discuss a hospital based cardiac catheterization department currently utilizing paper charting, the possible benefits of changing to electronic medical records (EMR), the need for the change, along with the barriers and organizational readiness regarding the change. The theoretical model of Kurt Lewin will be examined as it relates to the change. According to Brisson-Banks, an understanding of the need to change is the start of the change process (2009). Bringing change to an institution is just like the beginning of any nurse-patient relationship, a complete assessment must be performed before implementing care or change within the organization . Current methods of care and documentation must be assessed at the facility to determine what changes need to be made. The current standard of care is very high in all areas except for the paper documentation at the facility which will be called Hospital A. The staff is bright, cheerful and knowledgeable, but they are still using the same type of paper and pen charting system that was used...
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...Electronic Medical Records and the Future of Medical Charting JoEllen McMullan Dr. Maria Lauer May 19, 2012 ABSTRACT Electronic Medical Records (EMR) is the transformation of documentation for nurses, physicians, pharmacists and all healthcare professionals involved in a patient’s care. It incorporates all orders, notes, prescriptions, therapies and the like of a particular patient’s progress along their path of treatment and recovery. EMR will transform the medical field in ways healthcare providers could not have imagined a decade ago. While there are positive and negative aspects of EMR, the ultimate result is one of accurate, precise and up to date patient records and communication between all disciplines in real time. INTRODUCTION Electronic Medical Records (EMR) is by far one of the biggest advances in medical charting in recent history. For years, documentation, charting, orders, and virtually any communication between healthcare professionals has been done in the format of “paper charting”. In other words, each professional would document in a patient chart, their particular contribution to that patient’s care on any given day. Not only is paper charting inefficient with regards to time, it also leaves tremendous openings for inaccuracies and errors. ELECTRONIC MEDICAL RECORDS I chose to research Electronic Medical Records (EMR) for multiple reasons. I previously held a position in a cardiology office where we transposed...
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...COR301 Project Technology and Healthcare Lynze Wobig, Tiera Feller, Nicole Court-Menendez, Hannah Ford, Katie Johnson Background Most healthcare providers record patient information on what is called electronic medical record (EMR) or electronic health record (EHR). As of 2013, 78.4% of office-based physicians are currently using an EMR system (Electronic Medical Records/Electronic Health Records (EMRs/EHRs)). According to the American Recovery and Reinvestment Act of 2009, all public and private healthcare providers and other eligible professionals must have adopted and demonstrated “meaningful use” of EMR by January 1, 2014, in order to maintain their existing reimbursement levels of Medicaid and Medicare (University Alliance). In the late 1960’s, Larry Weed introduced the idea of what would develop into the current EMR. Previously, physicians would record patient information and encounters on paper. To a great extent, physicians resent the task of documentation, as it detracts from their primary task: taking care of patients (History of EMR). Physicians also resent the duplication of effort required with documentation, as every medication that is written on a prescription pad, every lab test ordered, every x-ray ordered has to be re-written in the chart to maintain a good record (History of EMR). The Regenstreif Institute developed the first medical record in 1972 and though this was viewed as a major advance in medical practice, physicians were not completely open...
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...Nursing and Healthcare January 18, 2016 Nursing with Technology “The application of nursing informatics knowledge is empowering for all healthcare practitioners in achieving patient centered care” (AMIA, 2016). Integrating technology with patient care is an important tool used today by health care professionals. The purpose of this paper is to discuss nurses managing care in their work environment with information technology. Work Environment and Managing Knowledge Understanding how difficult it is for nurses to provide care is essential to make changes that adequately promote a healthy work environment. Nurses must organize, prioritize, and have decision making skills. In order to achieve quality care and the best patient safety outcomes possible, nurses must be knowledgeable in their clinical setting. Information, data, and knowledge are of value to nurses in all areas of practice (ANA, 2015). When providing patient care, data is obtained and then aggregated for decision making. The appropriate use of knowledge involves putting it into action and applying it to the current situation in order to act and carry out the right action in the clinical environment (ANA, 2015). Nurses are skilled in managing and communicating information and this is essential to effective healthcare delivery. Managing Change in Workflow Electronic health records are being implemented throughout health care. For me, changing from paper charting to electronic documentation has been...
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...University Abstract This paper will demonstrate: A. How using computerized management systems could increase quality of care B. Why active nursing involvement in the planning, choice and implementation of the systems is important C. How handheld devices used by the nursing staff could be integrated into the management system for better quality care D. Security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and the Health Insurance Portability and Accountability Act (HIPPA) requirements impact the use of the systems E. How the new system can affect healthcare cost F. The benefits these new systems can offer to patient care and nursing care delivery with a recommendation and justification of the system the hospital should put in place In today’s modern healthcare environment it is important to provide a variety of technology based resources to nurses and other providers to ensure productivity and efficiency are maximized. This requires an effective understanding of available computerized management systems and what resources are available to ensure continued effective, efficient, quality care to patients. Keeping that perspective in mind while creating a technologically advanced environment in which to deliver that care is critical and of vital importance to maximize resources while providing a solid technology platform. The utilization of electronic medical records and nursing...
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...leisure, doing the latest Google search to find the answer to a nagging question. Technology has also been a boon in the world of medicine. Healthcare institutions are coming into the age of technology by implementing electronic health records (EHR) within clinics and hospitals. This paper will take the concept of technology and explore the meaning and affect to healthcare, and how it will affect nursing in general. Technology Relating to Healthcare In the healthcare arena, technology has made medical advances occur at an astounding rate. On a federal level, the executive and legislative branches of the federal government have launched initiatives to encourage the spread of health information technology. This came into play when the Health Information Technology for Economic and Clinical Health Act (HITECH) was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology (HHS.gov, n.d.). The act stipulates that, as of 2011, healthcare providers will be offered financial incentives for demonstrating meaningful use of electronic health records (EHRs). Incentives will be offered until 2015. After that point, penalties may be charged for failing to demonstrate such use. The act also established grants for training centers for the personnel required to support a health IT infrastructure. (Healthcare IT News, 2014). Development and adoption of a nationwide health information infrastructure is ongoing, leading to the ability to exchange...
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...derived from. Technology is the study or science of crafting, which are logia. The way in which healthcare is delivered is changing due to clinical information technologies. In an effort to support advancement and innovation of technologies in healthcare, research organizations are creating networks of delivery systems and health plans. The focus of this clinical information technology is centered on a prevention-based, consumer driven model of healthcare. The innovation of new technologies is dependent on many factors: Clinical accountability, consumer demand, research programs, medical advancements, population health targets and the capacity and resources as an industry for technology development. Innovation stimulates the industry to produce large quantities of medical devices and therefore promote them to the healthcare providers. The “clinical pull” of technology, is sometimes impervious with the “technology push" because physicians often resist the change of new technology due to its significance or its impact on day-to-day workflow (Protti, D). With the accessibility of computers, physicians are now able to look up information on his or her patients. Some physicians do not have the capability to write electronic prescriptions or digital health records. Physicians adopting clinical IT may be hindered by: Start-up and maintenance costs as well as significant costs of changing workflow that is necessary to use IT effectually. Promoting digital health data may inspire...
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...Healthcare Compliance and Coding Management Task 1 A. Discuss how you would carry out your various responsibilities as a coding manager by doing the following: A1. Analyze the job description for an inpatient coding position Managers should be aware of skill sets needed for an HIIM workforce, and recruit qualified staff to fulfill new job roles. Manager should review the job description each time they have a recruitment opportunity. They need to ensure the description outlines the work to be performed. It should be specific to the role of Inpatient Coder. The job description needs to include the position requirements, purpose, and all functions. It should also list the qualifications needed to be hired and successful. Sections of the description should also include education level, years of experience, specific knowledge needed, and any specific proficiency needed for the job. Be specific, before posting a job. Specification helps to minimize the wasted time and effort of the interviewer and interviewee. One of the Inpatient coder’s responsibilities would be reviewing all patient files for accuracy and recording into the computer; therefore a couple of key qualifications that should be listed would be, attention to detail and has medical terminology background. (Wilson, Jacqueline) Job descriptions are used by the manager to clearly set employee expectations for job performance. A2. Develop goals for a clinical documentation...
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...Electronic Documentation Nursing is a fast changing profession that has been vital to providing care in the medical setting. Throughout the past several years one of the most recognizable changes in the medical field is the transformation from paper charting to electronic forms of documentation. This has led to a decrease in the amount of paper charting by allowing nurses to use check boxes, cell formatting, and computer databases to keep patients records more accessible and organized. As new forms of technology become available we find that there are often flaws that need to be assessed and corrected to properly implement an optimal computing system. The clinical integration paper examines the positive and negative aspects of electronic documentation in the nursing field as it pertains to time management, patient safety and its efficacy. It was found that nurses spend the largest proportion of their time at the nurses station documenting and coordinating patient’s care with twenty five to fifty percent, which results in less time spent on patient care (Blair & Smith, 2012). This is alarming knowing that approximately a quarter to half of a nurse’s shift is done sitting in front of a computer documenting the day’s events. At Central Baptist Hospital I believe that more than half a day could be taken up by computer charting. From what I have experienced, a nurse may begin their shift with anywhere between four to six patients. These patients require a general...
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...Health Informatics and Healthcare Introduction Health informatics as defined by Shi and Singh 2015, as the application of information science to improve efficiency, accuracy, reliability of healthcare service, and inclusion of healthcare delivery. Healthcare informatics is becoming more complex than any other time in recent memory, the foundation needed to bolster device utilization and interoperability is more expanded, and there is even a more extensive scope of utilization to consider. As the populace ages, there is added pressure to provide patient care choices at home and in the community, implying that medical devices are getting to be a piece of a much bigger ecosystem spreading over the steadily developing continuum. This paper will analyze health informatics and discuss its benefits, trends, current issues, the impact health informatics in healthcare settings, and the role of health managers and the future. An interview will be conducted with a health professional to get their point of view of how health informatics have impacted their workplace, with further discussion of human resources, careers and the future. History The U.S. National Library of Medicine defines health informatics as a collaborative effort of designing, developing, adopting, and applying IT-based ideas in healthcare services delivery, management and planning (Kramer, 2012). In 1949, Gustav Wager of Germany founded the first professional organization for...
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...Changing Healthcare Professional nursing practice models enable nurses to control the delivery of care and the environments in which that care occurs. Nurses have input into decision making and can design innovations specific to a particular care setting. (Professional Nursing, 2011) Today the nursing profession is increasingly in complexity and versatility. The current healthcare reform is adding a broader scope of practice for nurses. The current standards of practice continue to evolve allowing nurse to practice at higher functioning than what was previously expected. This has caused a shift to a higher complexity and more advanced level to the profession. Advancement in science and technology has added to the complexity in the nursing practice during the past 20 years. Technology savvy nurses are required to meet the standard of practice as we continue to advance into a paperless world. These issues are raising the bar on the practice of medical care for all healthcare workers across the board. There is a wide spectrum of nursing expertise, education, and credentialing that is now necessary for the ever changing profession. Differentiated models of practice are supported by a clinical "ladder" or defined steps for advancement within the organization based on experience in nursing, additional education, specialty certification, or other indicators of professional excellence. (Erickson, 1998) Much higher expectations are placed on registered nurse new graduate. ...
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...Healthcare Technology Lisa Schirmeister HCS/212 Abstract Healthcare technology is always changing over the years. It is used in a wide range of area, from how diagnosis are made, treating different types of disease, and management of medical/health records. Technology has been used to asset in the different fields of healthcare. Studies are done to find ways to improve the way we take care and manage personal confidential information of our patients. Healthcare Technology As of 2011, per Center for Medicare and Medicaid Services all hospitals, doctor office and clinics shall convert from the standard paper records over to electronic records by 2014 to receive any incentive pay. Making electronic medical records and/or electronic health records one of the fastest growing medical technologies in the United States. Electronic Medical Records (EMR) vs Electronic Health Records (EHR) Both electronic medical record (EMR) and electronic health records (EHR) both are a computer bases documentation of your medical and health records. They are very similar to each other. They are the same of as paper medical charts, which contain information from test, labs, medications and doctor notes. EMR is mostly used for treatment and is not easily transmitted to other providers outside of the primary offices. EHR goes further and includes a more complete outlook to the overall patient history. EHR will allow patients to move their health record from one doctor to another. The use...
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...care services and an easier quicker way to chart a patient’s information and progress without taking away from the bedside care. McKesson is all about integrity, customer –first, accountability, respect and excellence. McKesson Horizon Emergency Care Decision Support System In an ever changing world, hospitals are being challenged every day with the increasing elderly in society and their multiple medical problems. The focus is more on the collaborating of hospitals, physicians, and tax payers. Due to all the problems that affect healthcare reform such as preventable readmission, decrease in reimbursements, infections due to hospital stays and financial penalties, patient safety has become the utmost concern for doctors, nurses and ancillary help. One way to collaborate between providers and payers is through a comprehensive electronic health record. A way to support safe, efficient and quality care is through meaningful use. What is meaningful use? Meaningful use is the use of a certified electronic health record in a meaningful use manner such as e-prescribing, for electronic exchange of health information to improve quality of health care and to submit clinical quality and...
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...your organization for more than a year. For the purpose of this paper the capitol purchase discussed is one of the electronic medical record. The federal government wants all medical providers to have an Electronic medical record by the year 2014. To keep up with the growing changes in technology allotting for this purchase will greatly affect the hospital system in many ways and prove its return on investment (ROI). According to Health Revenue.com, “ The goals of the EMR are: * EMR will help to streamline the medical records process by bringing structure to how it is done * EMR will help to ensure medical records are more complete and correct * EMR will help to providers follow drug authorization more thoroughly to protect against errors and abuse * EMR will reduce transcription costs * Fewer charts will have to be pulled because physicians will have easier access to information, no matter where they are * EMR will improve clinical messaging and thus improve the work flow and care of patients * EMR will help make charge capture more accurate (2011)”. This paper will explore the management and organization goals, the impact on the economic environment, and justifiable expenses and relate them to the mission of the organization in regards to the purchase. This purchase is beneficial in many ways to the health care organization and will overtime pay for itself many times over. Electronic medical records are a move all health care agencies are moving...
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