Electronic Health Records (also known as EHR’s) are the portions of a patient’s medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record. They are also called or known as electronic medical records, and electronic charts (Gartee, P. 311) EHR’s were first invented nearly 50 years ago. Since being invented, EHR’s have made entering and seeking medical information easier and faster for both doctors and nurses.
EHR’s also having many benefits that go along with them as mentioned before make it easy to search, find, and share patient’s information.This is much better than dealing with paper records. There are four main benefits that come from EHR’s, they are: alerts, trend analysis, health maintenance, and decision support.
EHR’s can also be stored in various different ways as well. They can be stored as digital imaging, text, and discrete data (Gartee, P. 157).
There is also a certain way they are organized and filed as well. Organizations of EHR’s are different than that of paper charts. Paper Charts are organized by source-oriented, problem-oriented, or integrated method (Gartee, P. 130). EHR’s on the other hand don’t use that particular format.They are stored on a omputer database by a method called random access. This data is instantly organized once it’s retrieved.
Once it has been organized the data is displayed in various ways, they are often referred to as views or reports. By the views EHR’s can rearrange to data if need be and at the same time they can show a source-oriented chart, problem-oriented chart, of integrated chart, the same way as paper charts (Gartee, P. 130) Some information that can be found in an EHR is a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and much more.
They can also show laboratory and test results as well. One of the unique features of EHR’s is that they can be shared with other providers across more than one health organization. They can be sent to laboratories, specialists, pharmacies, and school too. EHR’s show and contain information from all clinicians involved in a patient’s care (HealthlT. gov). Alerts, one of the four benefits are a special term for a message or reminder that is automatically generated by the system. There are many different types of alerts. Alerts help to warn providers when something goes wrong.
For example, if a patient has a certain allergy and they are prescribed and medication that could potentially arm them, the EHR will warn the clinician. That is why it is important it is important to always check the patient’s history before prescribing them anything (Gartee, Pl 62). Another form of alert is formulatory alerts.
This alert in particular is used to warn clinician if a certain prescription is not covered or honored by their insurance company. This will cause the patient’s insurance company not to pay for their medication.They may even have to go without or not get the full amount even. When a clinician fails to check the list for preferred, non preferred, and noncovered edications they cause both the patients and the doctor to have to go in and redo the prescription. The patient has the right to not except the prescription but they can also choose to get the prescription themselves(Gartee, P163).
Another benefit of HER’s is trend analysis. Trend analysis is used as a way to track a patient’s health. They show different test results and how they compare to each other.
Trends are usually shown in the form of a graph. The graphs make it easier to compare result of different times and dates. The graphing tools helps to form the data into a visual aid which helps with reading the data. Trends are not only used to track test results, but they also help monitor weight gain or loss and also blood pressure measurements (Gartee, P 161-162). A third benefit of HER’s is health maintenance.
Health maintenance in general is the maintenance of a patient’s health. To prevent disease or to detect them early is good health maintenance.If a patient doesn’t keep up with their health they can fall critically ill. There are two main parts to health maintenance; they are preventive care and immunization.
Preventive care is a type of care this reminds the patient when it is time for checkups and health screenings. A simple post card or letter can be sent to the patient to help remind them. These reminders help the patient to stay up to date with their health and to stay healthy.
This system is sometimes referred to as health maintenance systems or preventive care systems (Gartee, P. 59-160). Immunization is the second part to health maintenance. Immunizations should be taken by everyone throughout their life time. Patients are required to take certain vaccines at different times in order to prevent diseases and illnesses, although all vaccines cannot be taken all at once. HER’s help to keep up with all the vaccines the atient has taken the ones they have not taken.
As stated before, all vaccines are spread throughout the patient’s lifetime, but most vaccines are taken from birth up to 18 years of age.The EHR system will also notify the patient if they need to come in for a vaccine renewal (Gartee, P. 161). The last benefit of EHR’s is decision support. Decision support is the ability of EHR systems to store or quickly locate materials relevant to the findings of the current case (Gartee, P.
164). There are four different decision support systems, they are; prescriptions, medical references, protocols, and medication dosing. The prescription system deals with drug formularies.
They are used the look up drugs by name and so on.The electronic system helps to compare alternative brands, costs, indications for use, and treatment recommendations. The medical references system help access medical references from the EHR system. This can be done by clicking a simple link. Protocols can help with documentation of the patient’ exams and care as well. Protocols also help to make patient’s therapy plans for each existing condition.
Lastly medication dosing is used when the patient’s test results and previous medication osages are compared to see if there should any changes in the dosage.Usually the dosage changes if the patient’s test results change. Sometimes the dosage is changed because of certain side effects that is has on the patient (Gartee, P. 165). In conclusion, I find that since being invented electronic health records (EHR’s) have really paved the way for storing medical information. IVe learned that it is very important to store patient’s medical information and history properly.
One wrong mistake could actually harm the patient. They could receive the wrong vaccine, or give medication that they are allergic to.EHR’s is a serious matter and should be handled very carefully by both doctors and nurses. I feel that before any one tries to use this system that they should be well trained and knowledgeable about what it is that they are doing. IVe learned a lot about this particular system and I plan to take this knowledge with me throughout my nursing career.
References Richard Gartee. (2011). Health information technology and management. Upper Saddle River, NJ 07458.
Pearson. What is an electronic health record? Retrieved from https:// http://www. healthit.