Queensland Government (2004) cited that there are two
methods of health record, electronic and manual record keeping. While some
health care industry use electronic record system, most health care industry
prefer manual record keeping system making it easier capture information,
generate report and meet legal reporting requirements.
methods of health record, electronic and manual record keeping. While some
health care industry use electronic record system, most health care industry
prefer manual record keeping system making it easier capture information,
generate report and meet legal reporting requirements.
According to Healthcare Information and Management
Systems Society, (2011) the electronic health record (EHR) is a longitudinal
electronic record of patient’s health information generated by one or more
encounter in any care delivery. Setting include in this information are patient
demographist, progress noted, problems, medications vital signs, pass medical
history, immunization, laboratory data and radiology report etc.
Systems Society, (2011) the electronic health record (EHR) is a longitudinal
electronic record of patient’s health information generated by one or more
encounter in any care delivery. Setting include in this information are patient
demographist, progress noted, problems, medications vital signs, pass medical
history, immunization, laboratory data and radiology report etc.
Centers for Medicare and Medical Services (2009) cites
that, an electronic health records (EHR) is an electronic version of a patient
medical history, that is maintained by the provider over time, and may include
all of the key administrative clinical data relevant to that persons care under
a particular provider, including demographical progress note, problems,
medications, vital sight past medical history, immunization, laboratory data
and technology report potential to streamline the clinical workflow. The electronic
health record (EHR) has the potential to improve the quality, safety and
efficiency of patient care when fully implement. Use of HER can improve
communication among health care providers and increase team effort among
provider. It uses and reporting and eliminate concerns about the legibility of
paper medical record. Most importantly, its uses has been shown to have an
effect on quality, its uses has been shown to have an effect on quality of care
through optimize compliance with guidance (American Congress of Obstetrician and
Gynecologists, 2011).
that, an electronic health records (EHR) is an electronic version of a patient
medical history, that is maintained by the provider over time, and may include
all of the key administrative clinical data relevant to that persons care under
a particular provider, including demographical progress note, problems,
medications, vital sight past medical history, immunization, laboratory data
and technology report potential to streamline the clinical workflow. The electronic
health record (EHR) has the potential to improve the quality, safety and
efficiency of patient care when fully implement. Use of HER can improve
communication among health care providers and increase team effort among
provider. It uses and reporting and eliminate concerns about the legibility of
paper medical record. Most importantly, its uses has been shown to have an
effect on quality, its uses has been shown to have an effect on quality of care
through optimize compliance with guidance (American Congress of Obstetrician and
Gynecologists, 2011).
Broked (2010) cited that, the use of preassembled
orderly and documenting tools within an EHR may simplify the documentation
process, although care must be taken when using templates to avoid importing
previous notes without updating data, assessment, and plans. When using
template, the record must be reviewed and edited to ensures it accuracy,
documents the patient encounters. Record informality may reduce practice
variation and can standardize health procedures and follow-up. However, like
paper record, EHR, are only as accurate as the information entered into them.
EHR provides the benefits of improving the legibility of prescriptions,
potentially, reducing the risk of some medication errors. Health care providers
have the benefits of accessing information from online formulary assuming that
it is updated on an ongoing basis as well as providing real time medication
alert. It can also and with mediation reconciliation for each patient.
orderly and documenting tools within an EHR may simplify the documentation
process, although care must be taken when using templates to avoid importing
previous notes without updating data, assessment, and plans. When using
template, the record must be reviewed and edited to ensures it accuracy,
documents the patient encounters. Record informality may reduce practice
variation and can standardize health procedures and follow-up. However, like
paper record, EHR, are only as accurate as the information entered into them.
EHR provides the benefits of improving the legibility of prescriptions,
potentially, reducing the risk of some medication errors. Health care providers
have the benefits of accessing information from online formulary assuming that
it is updated on an ongoing basis as well as providing real time medication
alert. It can also and with mediation reconciliation for each patient.
According to Classmen (2010) the ability of EHR to
store and retrieve data makes it a logical tool to improve the quality of the
patient care. Using an EHR can consolidate patient information such as
diagnosis, medications and test result, which may enables provider to deliver
safer, more effective health care decision-making support, such as prompt and
reminders when test are due or when specific care does not meet guidelines,
provides the clinician with a tool to improve quality care.
store and retrieve data makes it a logical tool to improve the quality of the
patient care. Using an EHR can consolidate patient information such as
diagnosis, medications and test result, which may enables provider to deliver
safer, more effective health care decision-making support, such as prompt and
reminders when test are due or when specific care does not meet guidelines,
provides the clinician with a tool to improve quality care.
The enhanced ability of a health care provider to
clearly document all aspect of the encounter using an EHR may also ensure
proper billing and coding of optimized reimbursement.
clearly document all aspect of the encounter using an EHR may also ensure
proper billing and coding of optimized reimbursement.
According to Levington (2012) when fully functional
and exchangeable, the benefits of EHR, offer far more than a paper record
improve quality and convenience of patient care, increase patient participation
in their care, improve accuracy of diagnosis and health outcome, improve care
ordination and increase practice efficiencies and cost saving. Also Joel and
Madelyn (2007) outlines the benefit of electronic health records as follows;
privacy and security of data access control by patient and providers, greater
patient access to medical history data, increase quality of case note to be
easy to read and reduce risk or errors, improve efficiency and time management
of medical staff and efficient use of physical space, elimination of paper
records and charts, use paperwork and fewer storage issues, increased quality
of care, financial incentives, increase efficiency and productivity, better
patient care etc.
and exchangeable, the benefits of EHR, offer far more than a paper record
improve quality and convenience of patient care, increase patient participation
in their care, improve accuracy of diagnosis and health outcome, improve care
ordination and increase practice efficiencies and cost saving. Also Joel and
Madelyn (2007) outlines the benefit of electronic health records as follows;
privacy and security of data access control by patient and providers, greater
patient access to medical history data, increase quality of case note to be
easy to read and reduce risk or errors, improve efficiency and time management
of medical staff and efficient use of physical space, elimination of paper
records and charts, use paperwork and fewer storage issues, increased quality
of care, financial incentives, increase efficiency and productivity, better
patient care etc.
Electronic medical records seem to be the current
trend in health care and you will find many physician, allied health
professionals, pharmacist and hospital using some form of electronic recording
of patient data. Despite the many advantages of a more uniform approach to
documenting medical care and coordinating care when patient see several
specialists there are some disadvantages to electronic records. Furthermore,
training on electronic medical records software adds additional expense in
paying people to take training and in paying trainers to each practitioner.
Despite training most people creating medical records are now nurses and often
doctor’s unfamiliarity with technology. Especially when an EHR program is
implemented and significantly distracts from patient time as the doctor or
nurse struggle with unfamiliar equipment. Doctors have to divert focus to
figuring out how to enter things electronically and thus have less time for the
patient. Medical care in already crowed offices may be delayed when technology
is not reliable a frozen computer could steal minutes or more from patient care
for that day. It is also still easy to miss recording relevant detail or to
type in correct information.
trend in health care and you will find many physician, allied health
professionals, pharmacist and hospital using some form of electronic recording
of patient data. Despite the many advantages of a more uniform approach to
documenting medical care and coordinating care when patient see several
specialists there are some disadvantages to electronic records. Furthermore,
training on electronic medical records software adds additional expense in
paying people to take training and in paying trainers to each practitioner.
Despite training most people creating medical records are now nurses and often
doctor’s unfamiliarity with technology. Especially when an EHR program is
implemented and significantly distracts from patient time as the doctor or
nurse struggle with unfamiliar equipment. Doctors have to divert focus to
figuring out how to enter things electronically and thus have less time for the
patient. Medical care in already crowed offices may be delayed when technology
is not reliable a frozen computer could steal minutes or more from patient care
for that day. It is also still easy to miss recording relevant detail or to
type in correct information.
Along, with reduction in doctor/ patient time, some
people find that electronic medical records and their accompanying system have
depersonalized doctor’s visit or needed calls to a doctor office. Protocol of a
system may require for instance, any patient question to be emailed to a
doctor, even if the doctor passes that receptionist multiple time a day. This
can increase wanting time for call backs, or for doctor emails, especially if
emails are not checked regularly. Additionally there is not one electronics
medical records system, there are many streamlining patient care can only be achieved
when a single system is used, since two or more system may not work together.
If the hospital uses different EHR system than your primary care physician,
health records may not be available to the hospital or vice versa from hospital
to the physician, electronic medical records may reduce office paper work, but
they not coordinate care between several treating physicians, pharmacies and
allied health workers as they promise to do when different system are used by
each group.
people find that electronic medical records and their accompanying system have
depersonalized doctor’s visit or needed calls to a doctor office. Protocol of a
system may require for instance, any patient question to be emailed to a
doctor, even if the doctor passes that receptionist multiple time a day. This
can increase wanting time for call backs, or for doctor emails, especially if
emails are not checked regularly. Additionally there is not one electronics
medical records system, there are many streamlining patient care can only be achieved
when a single system is used, since two or more system may not work together.
If the hospital uses different EHR system than your primary care physician,
health records may not be available to the hospital or vice versa from hospital
to the physician, electronic medical records may reduce office paper work, but
they not coordinate care between several treating physicians, pharmacies and
allied health workers as they promise to do when different system are used by
each group.
Manual method makes use of the brain, heads and simple
tools such as pencil, pen paper etc. these tools require no electronic power in
the storage of health records (Unpublished material) advantages of manual
health records keeping according to the joint commission includes; less complicated
audit traits, the risk of corrupt data a much less, data loss is less of a
risk, particularly if records are stored in a fire-proof environment, problems
with duplicate copies for the same records are generally avoided.
tools such as pencil, pen paper etc. these tools require no electronic power in
the storage of health records (Unpublished material) advantages of manual
health records keeping according to the joint commission includes; less complicated
audit traits, the risk of corrupt data a much less, data loss is less of a
risk, particularly if records are stored in a fire-proof environment, problems
with duplicate copies for the same records are generally avoided.
The Queensland Government states that the
disadvantages of the manual health records keeping includes; much time
consuming, often the books are lost and the record officers is not aware of
this and once this is done the data will be completely lost, lots of manual
labour is required for the keeping, data
is stored in filing cabinets can get in the wrong hands and can be sued against
the hospitals, data is not always reliable as it is hand written and some human
errors might have occurred, retrieval of information is very slow as it has to
be searching in lots of register and this waste a lot of time, more data is
kept on register these are stored in filling cabinets and consumes a lot of
space.
disadvantages of the manual health records keeping includes; much time
consuming, often the books are lost and the record officers is not aware of
this and once this is done the data will be completely lost, lots of manual
labour is required for the keeping, data
is stored in filing cabinets can get in the wrong hands and can be sued against
the hospitals, data is not always reliable as it is hand written and some human
errors might have occurred, retrieval of information is very slow as it has to
be searching in lots of register and this waste a lot of time, more data is
kept on register these are stored in filling cabinets and consumes a lot of
space.