Primary Purpose Health Records

Patients are taking an aggressive role in their healthcare needs. Patients desire to in touch with their medical records. Medical professionals are utilizing the Electronic Health Records to implement current data into information necessary to provide quality care for the patient. Thereby, managing patients’ current, and past histories. To understand what is occurring today, one must recognize why patients are taking an active approach to their healthcare.

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

The federal requires the healthcare organizations to adopt and demonstrate the use of electronic medical records (EMR) or the electronic health records (EHR). They contain patient’s medical history and it

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

Records are kept to promote, provide and improve the care provided for patients. They are also used for audits and quality assurance carried out by the Care Quality Commission (CQC).

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

EHR was created to have a technical way to securely exchange private and personal medical health information in hopes to improve the quality of care, decrease medical errors, limiting paper use, reduction of health care cost, and increasing a person access to affordable health care. A mandate was created for EHR stating that health records can be accessible to all facilities with patients having the capability to access their own health records at any time. Ameliorating the quality and convenience of care given to a patient, allow for cost saving measures, engage the patient and family to participate in their care, improve accuracy of medical diagnosis, and enhance the efficiency of the overall outcome of the patients’ health.

The legal health record is the officially declared record of healthcare services provided to an individual delivered by a provider. Legal health records serves to support the decision made in a patient’s care. It documents the services provided as legal testimony regarding the patient’s illness or injury, response to treatment, and care giver decisions and as such, it serves as the healthcare’s organization legal records. The 10 types of data or information I will include in the legal health record are as follows; Identification number, Discharge summary notes, Physician progress notes, Nursing documentation, Multidisciplinary notes, Consent forms, Emergency department report, Laboratory reports, Diagnostic imaging reports, Advance directives, Patient billing and documentation.

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

Health information technique is biggest term in today’s era, technology used for various administrative, operations management, and direct clinical functions in health care organization. An electronic health record (EHR) is define by the Health Information Management System Society (HIMSS) as a longitudinal electronic record of patient health information generated by one or more encounter in any health care setting including patient demographics, progress

This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

In today’s medical field technology plays a big role when it comes to patient care. Technology is huge when it comes to giving the patient the best type of quality care when they are in the hospital. In the old days people would just write it down on a sheet of paper and record it by hand, which caused mistakes. Now with the Electronic Health Record those mistakes are drastically declining. Statistics have shown that using the Electronic Health Record has lowered Nursing mistakes as well as improved patient care. Our society has progressed through the years and has been introduced with the Electronic Health Record which has drastically improved our health care system. The Electronic Health Record provides great communication between

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.