Electronic health records Research
These components include the documentation of clinical activities, results from imaging and tests, provider-test order entry that has been computerized, and a decision support component. The utilization of EHR came as a solution to the need to have a system that would replace the inefficient, bulky, expensive, difficult to transport, and store paper records. The ineligible handwritings that contributed to numerous medical errors and jeopardized patient safety, and the need to have a more cost-effective system that would contribute to easy care transition contributed to the need to have EHR. Quality measures are fundamental in providing assurance to the users and patients that the system functions as intended. The rising cost of healthcare and the wavering consistency of its quality in the United States of America has resulted in using information technology to leverage health.
Clinical documentation in electronic health record encompasses four specific items. These items are the lists for medications, notes from the nurse regarding assessments, notes from the physician on the patient, and a list of health problems that the patient is facing. (Keyhani, et al. This component is used by caregivers to create documentation relating to the clinical information of the patient in a systematic manner. The notes and the lists contained in this component contain data indicating evaluations that have been done on the patient, orders for medicines made, interventions carried out, plans of care, consultations, and patient outcomes. This known as computerized physician order entry abbreviated as CPOE. This this is a system that allows physicians to enter instructions into the electronic health records on how patient treatment are to be treated.
The system then communicates this information to the relevant personnel in the healthcare team for an action to be taken. Research has shown that facilities using electronic health records with this component report fewer medication errors compared to those that lack (Aronson, 2010). When this component is combined with clinical decision support system, it has been shown to not only enhance medication safety but to also improve care quality and lower the cost of care. Their ineligibility contributed to numerous medication errors while their difficulty to be shared electronically made coordinated care slow and inefficient. They were also expensive to copy, store, or even transport. The second contributor was the need enhance efficiency of care delivery and productivity by ensuring that patient information was available in real-time when it was needed.
Additionally, there was need to assure quality of healthcare service given and safety of the patient through enhanced legibility of physician and nurse notes, ability to access these notes anywhere at any time before care, and timely reminders. Also, there was an urgency to meet expectations of both the pubic and the government for quality care at an affordable cost that would save taxpayers huge amounts of money. (Parsons, McCullough, Wang, & Shih, 2012). References Aronson, J. K. Medication errors. Side Effects of Drugs Annual, 32(2010), 903-922. A. (2009, january). Inpatient Computerized Provider Order Entry (CPOE). Retrieved from AHRQ National Resource Center for Health Information Technology: https://healthit. ahrq. G. Blumenthal, a. D. Use of Electronic Health Records in U. S. , Federman, A. , & Siu, A.
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