Electronic Health Records
The United States of America is among the countries that have the most developed health care system. But of which, comes with a price because the country invests heavily in the sector. The quality of services in the provision of healthcare is dependent on some factors, which include accuracy, integrity, and reliability of health information. To achieve such health care services, adoption of information technology on health, for instance, the use of electronic health records is paramount in making a transformed system of health care. Electronic health records (EHRs) are associated with benefits in the delivery of health care services and is composed of different methods through which patient information is stored. Each method has a purpose. EHRs also incorporates a workflow template where the healthcare givers record the follow-up activities.
Functions and Advantages Associated with EHRs
Electronic health record systems allow health care settings to store and also retrieve patient data for use by the nurses, the doctors, and at times patients themselves when they are hospitalized (Smith, 2009). Such technology is beneficial in that it assists the caregivers to avail a more efficient service compared to the use of memory and paper-based systems (Smith, 2009). Additionally, besides the fact the EHRs help in improving efficiency, the hospitals are enabled to develop, monitor, and report on matters concerning safety and quality (Smith, 2009).
Electronic health care records have also been identified as the best systems in the provision of constant care in the hospitals. EHRs avail certain patients’ history which helps the healthcare team to provide better support and diagnosis (Smith, 2009). Also, if the account is accurate, the physicians can prescribe medication that is necessary to the patient; thus cases of allergic reactions are not common (Smith, 2009). EHRs also help in the eradication of medical errors. That is, doctors improve the efficiency of healthcare services and keeps them on track to the achievement of the organization’s goals and objectives because it guides them from avoidance of duplication of testing (Smith, 2009). Some patients are prone to particular disease, and this can be diagnosed based on the history stored in the EHRs. Additionally, the same history avails data on the prescriptions given to the patient during their previous visit (Smith, 2009). Therefore, in such a case, a nurse can easily offer treatment in the absence of a doctor which in the long run makes the delivery of care services easy and fast.
Equally important, the system proves to be more superior to the use of paper because retrieval of data is simplified. Also, as indicated, a nurse can be able to treat a patient in an emergency, and there are no error repetitions (Smith, 2009). Additionally, in the case of such emergencies, use of electronic health records allows physicians n different hospitals to consult with each other therefore enhancing the delivery of services (Smith, 2009). The system also allows efficient and accurate billing processes.
Forms for Storing Patient Information in EHRs
The first form is the perfect Forms Inc. which utilizes the Adobe Flash online. The form is compatible for use in laptops, computers, and mobile phones. The second form is the form Router Inc. which is installed with many features. Some of these functions include that the form can be filled offline, has digital signatures, and also has tutorials on how the user can submit attachments and PDF forms (Koronios, Shou, Al-Hakim & Wu, 2016). Also, the form has tutorials indicating how one can capture the entire forms, attachments, and other forms of data into the sharing platforms (Koronios, Shou, Al-Hakim & Wu, 2016). The sharing feature allows doctors and nurses to consult online as well as from other physicians in the affiliate hospitals in cases of emergencies (Koronios, Shou, Al-Hakim & Wu, 2016). The last form is the software or storage as service form.
These records maintain information on patients separately. Some of the information found forms include the patient’s demographic information, the issues or problems the patient has identified relating to their health, and the prescribed medications (Koronios, Shou, Al-Hakim & Wu, 2016). Other information included in these forms include the test reports, and guidelines and suggestions offered by the doctors. In brief, the forms which are constituents of the entire EHRs system enhance the delivery of administrative processes for scheduling appointments, elimination of confusion, and also determine the eligibility of insurance (Koronios, Shou, Al-Hakim & Wu, 2016). They also avail certain patients’ history which helps the healthcare team to provide better support and diagnosis.
University of Phoenix Material
Patient intake and Follow-Up Workflow Template
Reference Figure 7-16 in Ch. 7 (p. 176) of your textbook Health Information Technology and Management.
Read the following scenario:
Dorothy has been experiencing constant headaches and fatigue. She decides it is time to visit her doctor, and she contacts her doctor’s office and schedules an appointment for the following day.
Complete the table below by identifying 10 to 12 steps you will need to follow when assisting Dorothy from patient intake to patient follow-up. Be as specific as possible. For example, Step 1 may be, “Dorothy walks into the doctor’s office and registers.”
|Step 1||Dorothy decided that enough was enough and that she needed to visit a doctor. She therefore calls the office where she asks for the Doctor’s schedule and when she should visit. She successfully books some appointment with the doctor the next day.|
|Step 2||Thanks to technology. After her call, she receives some notification that confirms her appointment. The notification is electronically generated. The notification id composed of details of the doctor whom she has booked appointment with, the room, and time she is expected to see the doctor.|
|Step 3||During the day of the visit, Dorothy arrives half an hour before the actual time of schedule. She used the time to confirm if information she had were correct. She also ensured that she could locate the room where the meeting was to avoid delays during the actual time.|
|Step 4||After the preliminary tour, Dorothy is provided with an electronic form where she was requested to fill out some information. She fills in her medical history details, the medications she was taking if any, and the reason why she decided to visit the hospital. In the form, she was also requested to indicate if she had some allergies.|
|Step 5||After filling the form, the nurse asks Dorothy to follow her to the exam room where several tests were done. The nurse examined Dorothy for any physical defects, where she also gathered information on Dorothy’s data such as weight, height, and blood pressure and later fed to the electronic health records.|
|Step 6||By utilizing the objective element of SOAP notes, that is, Subjective, Objective, Assessment, and Plan, the nurse will listen to Dorothy’s perception of her symptoms and offer explanation where needed. The nurse will also translate any medical symptoms that may not be clear to Dorothy and clarify where possible.|
|Step 7||On the same part, the objective part in this case, the doctor will take over and examine the patient. Upon completion of the tests, the doctor will review the history of Dorothy, and see if the current symptoms are related, or if it is a progressive growth of the symptoms. That is, the doctor will review reasons Dorothy has ever visited the hospital. The doctor will then proceed to the evaluation stage where they will ultimately decide on the diagnosis.|
|Step 8||The physician will then utilize Dorothy’s electronic health records to come up with a plan of treatment. The same records will be used as a guidance in offering treatment. The doctor will then order the prescriptions through the electronic health records and in the case that there will be negative interactions with the prescribed drugs, the EHR will notify the doctor. The prescriptions recommended by the doctor will then be transmitted to the pharmacy department where the physician will also confirm on the code that will be used for billing. The doctor will confirm the end of the session and later sign off.|
|Step 9||In the case that the doctor has requested the patient to take tests in the laboratory for further diagnosis, Dorothy will avail the sample to the laboratory team to gather more information about her condition.|
|Step 10||Dorothy will then be provided with education materials that will help her understand the nature of her illness. The materials will enable Dorothy too adopt a healthy lifestyle to ensure the condition is treated permanently.|
|Step 11||The nurse will then escort Dorothy on her way out and inform her that in the chance screening tests will be done, she will be notified.|
|Step 12||After the lab results are compiled, they will be sent to the doctor through electronic means where they will be reviewed, sent to Dorothy, and later stored in Dorothy’s electronic health record.|
In conclusion, electronic health records (EHRs) are associated with benefits in the delivery of health care services and is composed of different methods through which patient information is stored. Each method has a purpose. EHRs also incorporates a workflow template where the healthcare givers record the follow up activities. They allow health care settings to store and also retrieve patient data for use by the nurses, the doctors, and at times patients themselves when they are hospitalized. EHRs also help in the eradication of medical errors. That is, doctors improve the efficiency of healthcare services and keeps them on track to the achievement of the organization’s goals and objectives because it guides them from avoidance of duplication of testing. In brief, the forms which are constituents of the entire EHRs system enhance the delivery of administrative processes for scheduling appointments, elimination of confusion, and also determine the eligibility of insurance. They also avail accurate patients’ history which helps the healthcare team to provide better support and diagnosis.
Gartee, R. (2011). Health information technology and management. Upper Saddle River, NJ: Pearson
Koronios, A., Shou, Y., Al-Hakim, L., & Wu, X. (2016). Handbook of research on driving competitive advantage through sustainable, lean, and disruptive innovation. Hershey: Business Science Reference
Smith, P. (2009). Performance measurement for health system improvement: Experiences, challenges, and prospects. Cambridge Cambridge University Press