Medical Records Case tudy
ection I (Introduction) -- Liam O'Neill and William Klepack, the authors of Case tudy # 3, Integrating Electronic Medical Records and Disease Management at Dryden Family Medicine, begin their published findings by introducing readers to the concept of electronic medical records (EMR). The authors immediately narrow their focus to the adoption and implementation of EMR by Dryden Family Medicine, a rural family practice located in upstate New York, and explain that "for smaller group practices, electronic medical records (EMR) adoption is a huge undertaking that poses significant risks" (O'Neill and Kleback, 2010). The Introduction section then covers the multitude of obstacles encountered by small group practices attempting to convert to EMR, including the limited information technology experience possessed by most staff members, and the constant concern of budgetary constraints. Finally, the authors seek to clarify the emphasis of their study by stating that their focus remains on…...
mlaSection III (The Vendor Selection Process) -- This section covers the process employed by Dryden Family Medicine to direct the transition to EMR. The authors begin with the steering committee established in 2002, which was "composed of one physician, the office manager, the nursing supervisor, and the front-desk supervisor" (O'Neill and Kleback, 2010). The issue of vendor fallibility is explored, as the choice of an unprepared or unskilled billing systems provider could easily undermine the practice's 50 years of record keeping. Finally, the reader is guided through the EMR vendor selection process, from the industry trade journals to consultations with fellow family practices that have previously implemented EMR systems.
Section IV (Stages of EMR Implementation) -- This section includes a detailed timeline of the EMR implementation process utilized by Dryden Family Medicine. Found in Table C3.1 and Figure C3.1 are various benchmarks in the EMR adoption process, such as "August 2003 Prescriptions generated electronically and faxed to pharmacies" and "March 2005 Patient education literature is scanned into the system and linked to EMR" (O'Neill and Kleback, 2010). The informative tables are followed by a thorough analysis of the three-stage process used to effectively introduce EMR strategies to Dryden Family Medicine's overall system. The section concludes with a concrete example of EMR-based improvements, as the authors recount a 2005 incident involving the painkiller Bextra and a Food and Drug Administration recall that patients were notified about immediately.
Section V (Impact on Job Responsibilities) -- The purpose of this section is to determine the impact of implementing an EMR system which clearly "resulted in changes in the job descriptions and responsibilities of all members of the practice" (O'Neill and Kleback, 2010). The authors observe several instances involving physician's problematic interaction with
EMR
Electronic Medical Records
Electronic Medical Record (EMR) keeping can definitely add efficiency into the modern healthcare system. However, this efficiency might be associated with some hidden costs. One example of such a cost will be due to the loss of privacy that is allowed by shared records. Not only will doctors be able to see your entire medical history, but other agencies that you might not want to share information with will have access as well. Therefore, there are both advantages and disadvantages associated with the move to a digital system.
"Imagine a world where everything important about a patient is known to the physician the first time that patient presents," says Andrew Rubin, vice president for NYU Medical Center Clinical Affairs and Affiliates in New York City (Mann, N.d.).
Doctors have full access to a patient's medical health history has the potential to reduce errors and improve patient care. In many cases…...
mlaWorks Cited
Mann,, . D. (N.d.). Technology Plays Key Role in Health Care Reform. Retrieved from WebMD: http://www.webmd.com/health-insurance/technology-plays-key-role-in-health-care-reform
The master patient index (MPI) value was mainly liked by the personnel in the medical record section.
The Golden 90s
Equipped with MPI and record-keeping growth, software designers sustained to generate and progress with a new emphasis on individual hospital sections. Auxiliary department purposes, for example radiology and laboratory showed to be fairly adaptive to software that is fresh and innovative, and computer healthcare applications start to show on the market. Patient test outcomes that instigated in the laboratory and radiology department now too were obtainable via computers nonetheless again with limit as the outcomes were separate and were not linked to one another, or to any other software for instance that being done with the patient registration. A lot of these applications had basically been marked as "source" governments, and they were not courteous to assembly athwart the healthcare aptitude. This is the state that mechanization in healthcare found itself…...
mlaReferences:
Holden, R.J. (2011). Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety. Cognition, Technology & Work, 13(1), 11-29.
Kaliyadan, F., Venkitakrishnan, S., Manoj, J., & Dharmaratnam, a. (2009). Electronic medical records in dermatology: Practical implications. Indian Journal of Dermatology, Venereology and Leprology, 75(2), 157-61.
Kochevar, J., Gitlin, M., Mutell, R., Sarnowski, J., & Mayne, T. (2011). Electronic medical records: A survey of use and satisfaction in small dialysis organizations. Nephrology Nursing Journal, 38(3), 273-81.
Kurbasic, I., Pandza, H., Masic, I., Huseinagic, S., Tandir, S., Alicajic, F., & Toromanovic, S. (2008). The advantages and limitations of international classification of diseases, injuries and causes of death from aspect of existing health care system of B&H. Acta Informatica Medica, 16(3), 159.
Medical Records
Each individual/entity in this scenario has an agenda. Sandra: is a child under both State and Federal Law; her immediate concern is hiding her sexual abuse by her stepfather; however, hospital administration must be concerned with her best interests on three counts: first, because she is a patient; secondly, because she is a child; third, because she is an allegedly abused child. Mrs. Anderson: is both the patient's parent and a mid-level hospital administrator; her immediate concerns are obtaining and editing medical records to keep her family together on religious grounds; however, the patient's best interest, both as a patient and a child, conflict with Mrs. Anderson's concerns. The hospital: is bound by both Federal and State law; its immediate concerns are serving the bests interests of its patient, who is also a child, while honoring Mrs. Anderson's rights as a parent/representative of the minor patient. In this…...
mlaWhat Should Be Said To Mrs. Anderson About Her Access To Records, Including Laws Regulating Access To And Disclosure Of Medical Records/Information Of A Minor Receiving Reproductive Care/Treatment.
Mrs. Anderson should be told that she is there solely in her capacity as a parent of a minor patient, that her capacity as a mid-level administrator is irrelevant to her instant rights, that any attempt to use her authority as a mid-level administrator to obtain her daughter's original records is an abuse of her authority, and that altering original medical records by unauthorized personnel (i.e., her), is illegal. She should also be told that her work as a mid-level administrator gives her greater insight into laws and hospital policies: the law and the patient's well-being supersede religious beliefs; that the record is what the record is and it cannot be changed by her; that access to the records is severely restricted by law and by hospital policy; that medical records are rarely released immediately upon request in any event; that medical records are not normally released to individuals in any event; rather they are released from facility to facility for purposes of treatment; that it is the provider's judgment that must determine whether it is in the patient's best interest to release the records; that in the instant case, neither the records nor a copy of the medical records will be released to her because, in the provider's judgment, release would not be in Sandra's best interests.
Though Sandra is a minor and Mrs. Anderson is her parent/representative, HIPAA recognizes that there may be circumstances in which medical records should not be released to the parent/representative of a minor (U.S. Department of Health and Human Services, 2012). In fact, even if the California law did not provide guidance, HIPAA provides that the hospital has discretion to provide or deny access, so long as that decision is made by a health care professional using his/her professional judgment (U.S. Department of Health and Human Services, 2012). As it happens, California Health and Safety Code §123115 (a)(2) provides that she is not entitled to inspect or obtain copies of the records when the health care provider determines in good faith that access would detrimentally affect the hospital's professional relationship with Sandra, or Sandra's physical safety or her psychological well-being (California State Legislature, 2003). In this case, release of Sandra's records to her mother would harm Sandra in all three aspects. Releasing the records to her mother could detrimentally affect the hospital's relationship with Sandra because she has advised us that she does not want her mother to
The issue of misplaced or lost patient files is also gotten rid of. These advantages aid in producing a marked rise in the health connected security of patients and the welfare of patients (Ayers, 2009). Furthermore, electronic medical records and patient care are identical in that such systems effortlessly permit restrictions to be placed upon end users' admission to specific information of the patient. This personal security feature is likewise significant to meeting a patient's confidentiality anxieties.
Figure 4 Electronic medical records and their advantages with patients (Slaughter, 2000).
The Benefits of access that is easy to each patient's comprehensive medical information, and the ability for physicians to rapidly take part in medical records and organize patient care. Even though every department at SMG utilizes the EM, it is particularly valuable in the Urgent Care Center when rapid admission to a patient's material can make all the change in medical and…...
mlaReferences:
Angst, C.M., Agarwal, R., Sambamurthy, V., & Kelley, K. (2010). Social contagion and information technology diffusion: The adoption of electronic medical records in U.S. hospitals. Management Science, 56(8), 1219-1241.
Ayers, D.J., Menachemi, N., Ramamonjiarivelo, Z., Matthews, M., & Brooks, R.G. (2009). Adoption of electronic medical records: The role of network effects. The Journal of Product and Brand Management, 18(2), 127-135.
Berner, E.S., Detmer, D.E., & Simborg, D. (2005). Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. Journal of the American Medical Informatics Association, 12(1), 3-7.
Brooks, R., & Grotz, C. (2010). Implementation of electronic medical records: How healthcare providers are managing the challenges of going digital. Journal of Business & Economics Research, 8(6), 73-84
Organizing Medical ecords:
One of the most important factors for proper billing and coding starts with the development of a well-documented and organized medical record. This is largely because patients and health care providers are normally faced with the need of keeping and providing medical records. These individuals are usually responsible for providing copies of their medical records to health care specialists and consultants. In most cases, medical records are typically organized in various ways including:
Source-oriented ecords:
This is a traditional patient record model that maintains reports depending on the source of documentation with each source of data containing a labeled section known as sectionalized record. In this format, all documents created by the nursing staff are located in record's nursing section, medical section for physician-generated documents, and radiology section for radiology reports (Green & Bowie, 2010, p. 89).
Problem-oriented ecords:
This is a more systematic method of documentation that contains four components i.e.…...
mlaReferences:
Green, M.A. & Bowie, M.J. (2010). Essentials of health information management: principles and practices (2nd ed.). New York: Cengage Learning.
Rajakumar, M. (n.d.). Numbering and Filing System. Retrieved November 19, 2011,
from http://laico.org/v2020resource/files/NumberandFilingsystem.html
Weber, G.I. (n.d.). Achieving a Patient Unit Record Within Electronic Record Systems. Retrieved from University of Missouri -- Kansas City website: http://sce.umkc.edu/~leeyu/Mahi/medical-data9.pdf
Home Computerized Medical ecords
Computerized Medical ecords
Advantages
One major advantage of computerizing medical records is that this method saves money and time for medical professionals. A traditional record system consists of files stored in a filing cabinet or other physical location. Files stored this way can easily become lost or displaced; the t time and resources to track down files that are missing can have a huge effect on the efficiency, effectiveness and revenue of the medical practice. Missing files can result in duplicate paperwork, lost time and productivity. For example, a medical office assistant that spends 20 hours a week searching for missing files, at an hourly rate of $15 costs the office over $14,000 a year in wasted time and money! Computerized medical records eliminate all these issues. With files kept in one database, they can be quickly located and retrieved. esulting in less rework and less time wasted.
Another key…...
mlaReferences
Computerized medical records: Security, privacy, and confidentiality. (n.d.). Med League. Retrieved November 8, 2011, from www.medleague.com/blog/2010/10/13/computerized-medical-records-security-privacy-and-confidentiality
National-Academies.org | Newsroom. (n.d.). News. Retrieved November 8, 2011, from http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=13269
Safety risks seen in computerized medical records . (n.d.). STL Today. Retrieved November 8, 2011, from http://www.stltoday.com/news/national/safety-risks-seen-in-computerized-medical-records/article_3de79c9a-da52-5c83-8236-fcad7e0b6991.html#ixzz1dDxPqTTI
The Benefits, and Potential Side Effects, of Sharing Medical Records Online - Knowledge @ Wharton. (n.d.). Knowledge @ Wharton. Retrieved November 9, 2011, from http://knowledge.wharton.upenn.edu/article.cfm?articleid=1846
computer-based vs. paper-based medical records, and discuss which are better. ecord-keeping is an important and vital part of any medical practice. Keeping medical records ensures the health and wellness of patients by tracking their overall care and health history. ecord-keeping is important for many purposes including legal information, health information and documentation, and keeping information that must be shared for professionals that are documented caregivers for patients. Thus, determining the best method for keeping records is vital to the patient and clinics success.
Keeping paper-based medical records has been the standard for some time. Paper records provide a wealth of information. Only recently has the computer been seen as an effective tool for keeping medical records. Computers are now considered a confidential and safe tool for keeping medical records. There are many advantages of computer-based medical records. Computers have the ability to store a lifetime of health data in a…...
mlaReferences:
Lovis, C., Baud, R.H., & Planche, P. (2000). Power of expression in the electronic patient record: structured data or narrative text. Int J. Med Inf, 58-59, 101-110.
Shortliffe, E.H., & Perreault, L.E. (2001). Medical informatics: Computer applications in health care and biomedicine. 2nd ed. New York: Springer.
Tang, P.C., LaRosa, M.P., & Gorden, S.M. (1999). Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. J Am Med inform Assoc, 6(3), 245-51.
Records of full medical operations are stored in primary storage facility, and are filed numerically in an attempt to realize efficiency. The filing system of an organization is usually numerical, and is based on terminal digits of the patient's HRN (Health Record Number). An up-to-date copy of the Paper-based medical records register should be kept in the file at all times. This may be the system used most of the time to locate medical records but it also provides a system to search when the power fail. Ideally, two-colored coded number of stickers are placed on the protruding right hand side back cover, of the medical record cover. These numbers normally match the last numbers on the HRN on the register. The digits that are colored, and in the case where they are misplaced, then it will show that the charts are misfiled. Ideally, file location can be determined…...
mlaConsequently, in an attempt to ensure efficiency in chart filing system, it is vital for the management to retain and update the interim data collection tool at the health center and notify the information management officer of changes requiring central updating- HRN, given name and surname (Fordney & Follis, 2007).
Purpose of Paper Medical Record
The function of paper medical record is to provide guidelines for maintenance medical activities, its contents, security, and patients' confidentiality. However, the medical records available should always conform to the set requirements especially the rules and regulations guiding medical records. These laws are structured in federal and state constitutions. In addition, it provides a distinct definition
records are being replaced with electronic records in all fields. This is especially important in the medical field, where stores information is useful when a patient or doctor must access it in seconds. Computerized systems, however, have not achieved the same degree of utilization in the medical field as in other business fields, for instance, either in the Western world or elsewhere.[footnoteRef:1] However, as mentioned above, these systems can be vitally important. According to some, Electronic medical record systems lie at the center of any computerized health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerized medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in many western countries.[footnoteRef:2] Thus, though there are problems,…...
mla"With the federal government poised to spend $20 billion or more on healthcare IT as part of the economic-stimulus bill now before Congress, it's a good time to get to know these companies."[footnoteRef:3] [3: Hamilton, D. (2009). The Top Ten Electronic Medical Record Vendors. CBS Interactive Business Network. Retrieved October 30, 2011, from . ]
According to this, the striking thing is the concentration within the sectors. The study further states, "Meditech, a privately held Boston-area company, holds more than a quarter of the market; McKesson and Cerner, numbers 2 and 3 on the list, control another 27%. All told, the top six companies -- excluding in-house systems -- are responsible for three-quarters of the EHR installations in hospitals around America."[footnoteRef:4] [4: Hamilton, D. (2009). The Top Ten Electronic Medical Record Vendors. CBS Interactive Business Network. Retrieved October 30, 2011, from .]
The paper thus provides a ranging of the top ten vendors, which can be useful and which is as follows[footnoteRef:5]: [5: Hamilton, D. (2009). The Top Ten Electronic Medical Record Vendors. CBS Interactive Business Network. Retrieved October 30, 2011, from .]
Financing the Healthcare Delivery System
Mr. Y is a patient with heart failure and has visited the emergency room twice in the last three weeks for shortness of breath. He is a very nice gentleman with limited literacy and e-literacy. Some of the problems Mr. Y faces include being homeless, difficulty in complying with his heart failure medication regime, and diet restrictions. He gets admitted to the hospital to stabilize his heart failure. Given his current situation and the numerous challenges he faces, there are concerns regarding what will happen to Mr. Y upon discharge from the hospital.
However, Mr. Y's situation is an example of an issue that is addressed by the Patient Protection and Affordable Case Act, which was enacted by former President Obama in 2010 as part of health reforms to enhance the affordability and accessibility of healthcare in the U.S. The provision/title of the Patient Protection and Affordable…...
mlaReferences
Cutler, D.M. & Feder, J. (2009, June). Financing Health Care Reform: A Plan to Ensure the Cost of Reform is Budget-neutral. Retrieved January 30, 2017, from https://www.americanprogress.org/wp-content/uploads/issues/2009/06/pdf/financing_health_reform.pdf
Hass, S. A. (2014). Health reform act: New models of care and delivery systems. Retrieved from Health Reform Act: New Models of Care and Delivery Systems
HMS (healthcare management systems) and EMRs (electronic medical records) have been widely praised as significantly adding to patient safety and quality of care. They can permit healthcare institutions to keep more accurate databases on patients, all in one location, and can ensure that a patient’s full medical records are available, even if the patient is not responsive and the patient’s family is not available. Prior treatments, current and past medications, and patient allergies can all be easily accessed with a point and a click. But transitioning to such healthcare systems is not always without issues and often involves a significant investment of time and money.
First of all, from a staffing point of view, change management is needed to ensure that the transition is effective. One helpful way to view change of any kind within an organization is that of Lewin’s Change Management Model, which suggests that organizations must first have…...
' Since the paper is only used as 'back up' this means that the files are under lock and key, in a centralized location or in the department generating the data. They do not circulate throughout the facility, ensuring a greater chance of misplacement or security compromises. But even in this instance, errors can occur -- timely record-updating and writing times and dates next to new information when it is added to a patient's file is essential, to ensure that there is not a discrepancy between the patient's data kept in two different locations. In fact, one worker at one of the larger facilities expressed dissatisfaction with the paper back-up method: "Keeping everything together either electronically or on paper not both. Causes too much confusion," she or he wrote.
Unfortunately, in large and small facilities, even with security procedures such as password protections for digital data, safety concerns remain. Concerns about…...
Medical Abbreviations
How can eliminating abbreviations reduce errors?
In the medical profession, time is everything. To make documentation as expeditious as possible, a series of abbreviations have been accepted in records. This has been considered an acceptable practice as much as calling a registered nurse an "RN." The problems occur when people are unclear about the abbreviations mean or if a set of letters can have more than one meaning. For example, there is the abbreviation "CA" which means cancer and then "Ca" which is calcium. Another example is "a" which can mean both "artery" and "before" (Medical 2011-page 1). It is very easy to misread abbreviations when medical staff is in a hurry. Imagine the problem if a "q.w." which is take weekly was confused for a "q.v." which is take as one wishes. If the terms were written out rather than abbreviated, these potentially dangerous situations could be completely avoided.
Should…...
mlaWorks Cited:
Berman, Jules. (2008). "Specified Life." Biomedical Informatics.
Greenall, Julie (2006). "Safe Medication Practices." Hospital News.
"Medical Abbreviations Glossary." (2011). JD-MD.
Barnsteiner JH. Medication reconciliation: transfer of medication information across settings -- keeping it free from error. Am J Nurs. 2005;05(3 Suppl):3-6.
This article evaluates the need for proper medication reconciliation across various nursing settings. This article is important as emphasis is placed on error free reconciliation which is very important for proper client service and treatment.
Bullough, Vern L. and Bonnie Bullough. The Emergence of Modern Nursing (2nd ed. 972)
This reference emphasized modern nursing and many of the practices and advances of nursing over the years. This is important as it provides a historical perspective of medical reconciliation. A historical perspective is needed to better understand improvements that will need to be made in the future.
D'Antonio, Patricia. American Nursing: A History of Knowledge, Authority, and the Meaning of Work (200), 272pp
This reference provides further evidence into the history of medical reconciliation and recommendations on improvements that should be made to the process.
4.…...
mla13. Rogers G, Alper E, Brunelle D, et al. Reconciling medications at admission: safe practice recommendations and implementation strategies. Jt Comm J Qual Saf. 2006;32:37-50
14. Snodgrass, Mary Ellen. Historical Encyclopedia of Nursing (2004), 354pp; from ancient times to the present
15. Sullivan C, Gleason KM, Rooney D, et al. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual. 2005;20(2):95-98
Electronic medical records, which refer to medical records that are not only stored in electronic systems (which includes almost all medical records in the modern world, with the exception of some medical records maintained in non-industrialized nations), but that are accessible to multiple healthcare providers across different platforms. The question is whether these records are able to improve quality of care by allowing healthcare providers to get a full picture of a patient’s medical history, as well as any presenting concerns or issues, as soon as the patient presents for medical treatment. It would seem like the....
1. The benefits and challenges of switching to Electronic Medical Records in healthcare settings.
2. The impact of Electronic Medical Records on patient care and outcomes.
3. The role of Electronic Medical Records in improving healthcare efficiency and reducing costs.
4. The importance of data security and privacy in Electronic Medical Records systems.
5. The potential for interoperability and data exchange between different Electronic Medical Records systems.
6. The future of Electronic Medical Records and the potential for advanced technologies like artificial intelligence and machine learning.
7. The ethical considerations and implications of Electronic Medical Records, particularly in regards to patient consent and data sharing.
8. The....
Impact of Electronic Medical Records on Patient Care
The benefits and challenges of using electronic medical records (EMRs) in healthcare delivery
How EMRs have improved the accuracy, efficiency, and accessibility of patient information
The role of EMRs in reducing medical errors and improving patient safety
The potential risks to patient privacy and security associated with EMRs
The impact of EMRs on the patient-physician relationship and trust
Technological Considerations for EMR Implementation
The key technological requirements and challenges for successful EMR implementation
The different types of EMR systems available and their respective strengths and weaknesses
The importance of data interoperability and standards....
Research-Based Essay: Impact of Nurse-to-Patient Ratios on Patient Outcomes
Introduction
The nurse-to-patient ratio is a key factor that influences patient care quality and outcomes. Extensive research has demonstrated a strong correlation between lower nurse-to-patient ratios and improved patient outcomes, highlighting the critical role that nurses play in providing safe and effective care.
Evidence
Reduced mortality: Studies have shown that patients cared for by nurses with lower caseloads experience lower mortality rates. A study published in the Journal of the American Medical Association found that for every additional patient assigned to a nurse, the risk of in-hospital mortality increased by 7%.
Shorter hospital stays:....
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