Nur 3062 chapter 5

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Chapter 5

Electronic Health Records


Evolution of Electronic Health Records

Terms used to describe automated records• Computerized medical record• Computer-based patient record• Electronic medical record• Electronic health record


Longitudinal Patient RecordA 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.


Advantages of Manual Records• Low start-up costs• Training of staff is simple• Requires less technically trained staff• Available because there is no downtime


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.


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


Advantages of Automated Records (Continued)

• Views can be customized• Updates occur easily• Customized retrieval of information• Enhanced security• Reduction in administrative costs


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.


Transition to Electronic Records• Scanning of documents• Hybrid records• Record transitional template


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.


Stakeholders in a RHIO• Hospitals• Physicians• Patients• Health plans and insurers• Public/governmental health agencies


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


Components of Electronic Health Records

• Characters• Fields• Records• Files• Data• Information


Patient Registration Screen


Administrative and Clinical Applications

• Registration-admission-discharge-transfer system (RADT)

• Clinical applications– Patient monitoring systems– Pharmacy – Laboratory– Radiology– Nursing– Medical documentation


Patient Registration Demographic Information


Clinical Information:Patient History


Patient Intake Screen at Exam


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.

Nur 3062 chapter 5

Health & Medicine

Transcript of Nur 3062 chapter 5