Health
records is the systematic documentation of a patients’ medical history and care across time with a particular health care provider.
The health record includes a variety of types of “notes” entered over
time by health care professionals, recording observations and administration of
drugs and therapies, orders for the administration of drugs and therapies, test
results, x-rays, reports, etc.
records is the systematic documentation of a patients’ medical history and care across time with a particular health care provider.
The health record includes a variety of types of “notes” entered over
time by health care professionals, recording observations and administration of
drugs and therapies, orders for the administration of drugs and therapies, test
results, x-rays, reports, etc.
Striking similarities and differences between
health record of old and that of modern time
health record of old and that of modern time
Health
records of old can be referred to as manual documentation of patients’ health
records while modern time health records is referred to as electronic health
records.
records of old can be referred to as manual documentation of patients’ health
records while modern time health records is referred to as electronic health
records.
Similarity between old and modern time health
records
records
1.
Both records contain sensitive patients, data necessary for effective
management of patients.
Both records contain sensitive patients, data necessary for effective
management of patients.
2.
Need adequate confidentially to ensure secrecy of patients’ data by
keeping them from unauthorised users.
Need adequate confidentially to ensure secrecy of patients’ data by
keeping them from unauthorised users.
Differences between health record of old and that
of modern time
of modern time
|
Modern time form of health records (Electronic health
records) |
Health
records of old
(Manual
documentation) |
|
They are very convenient to
carry and transfer from one person to another since they can be sent as attached files. |
|
|
They cannot be easily accessed
by an unauthorised user especially if the computer is password protected. |
They are easily accessed by
unauthorised users since they are kept on the shelf and cannot be password protected. |
|
Large amount of information can
be stored conveniently. |
It becomes cumbersome to store
information when dealing with large amount of information. |
|
They are stored as soft copy
folders in the computer. |
They are stored in hard copy in
office flat files in the shelves |
