Recently, I received a request to perform an x-ray on a patient who was newly admitted to the hospital’s intensive care unit. After explaining that I was there to perform an x-ray of her chest, her first remark was that she did not want to have another x-ray because she had an hour before in her doctor’s office. She was adamant about the fact that we should be able to view the image that she had in the doctor’s office within the hospital. I responded that because the exam was done in the doctor’s office and not the hospital, her physician would be unable to gain access to the image or results of the exam. Unfortunately, she was not thrilled with my answer and refused the exam. This example is one reason why the patient’s information should be recorded electronically.
Legislation passed during the Bush administration which requires an electronic health record (EHR) to be established for all Americans by 2014(Hebda& Czar, 2009). An EHR can be defined as a “digital collection of patient’s medical history and could include items like diagnosed medical conditions, prescribed medications, vital signs, immunizations, lab results, and personnel characteristics like age and weight”(Hebda& Czar, 2009,page 295).
The electronic record would replace the current method of recording patient data which is the paper chart. The data in the paper chart is compiled of handwritten entries and other printed documents (Englebert &Nelson 2002). In my dealings with paper charts, I have often not been able to clearly read a physician’s order and have had to call for confirmation. Misunderstandings can occur due to illegible handwriting, which lead to errors that risk the patient’s care (Englebert &Nelson, 2002).
Generally, an electronic record is beneficial because information is more accurate, productivity is increased, and there is greater access to patient data (Hebda & Czar,