Topic > Electronic Health Record - 1280

After decades of paper health records, a new type of recordkeeping has emerged: the electronic health record (EHR). EHR is an electronic or digital concept of an individual's past and present medical history. It is the primary storage location for data and information about healthcare services provided to an individual patient. It is maintained by a provider over time and can be shared between different healthcare settings via networked information systems. Such records may include key administrative and clinical data relevant to that person's care under a particular provider. Examples of such documents may include: demographic information, doctor's notes, problems or injuries, medications and allergies, vital signs, medical history, vaccinations, laboratory data, radiology reports, and billing information (www.cms.gov). The purpose of the EHR can be understood as a comprehensive record of patient encounters that automates access to information and has the potential to streamline the clinician's workflow in a healthcare setting. It also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcome reporting (www.cms.gov; “Electronic Health Records” , 2010). The main purpose of the EHR is to improve and strengthen the relationship between doctors and their patients. It is also an attempt to reduce patient suffering due to medical errors and to help healthcare providers make better decisions in providing quality care. Data collection can also prevent duplicate tests, delays in treatments and procedures, prescription interactions, automate templates and/or forms, and improve clarity...... middle of paper ......p:/ /en.wikipedia .org/wiki/Health_Level_7Privacy of the medical record. (2010, August 9). Retrieved August 10, 2010, from http://epic.org/privacy/medical/Tegan, Anne, et al. “The Impact of the EHR on HIM Functions.” Journal of AHIMA 76, no. 5 (May 2005): 56C-H. Sprague, Lisa. (2004, September 29). Electronic health records; How close? How far to go? Retrieved August 10, 2010, from https://www.nhpf.org/library/issue-briefs/IB800_EHRs.pdf Leavitt, Mark. (2008, September 25). The positive impacts of certification: greater than you could imagine. Retrieved August 11, 2010, from http://ehrdecisions.com/2008/09/25/the-positive-impacts-of-certification-%E2%80%93-bigger-than-anyone-realized/Morton, Mary. (2010). Acceptance factors of electronic health records in ambulatory care; a survey of doctors' perceptions. Retrieved August 11, 2010, from http://library.ahima.org/xpedio/groups/public/documents/ahima