Electronic health records (EHR) digitally store patient health information including medical history, treatment, allergies, medications, and lab results. EHRs allow for the management of health data using modern techniques and provide clinicians tools for clinical decision support. While EHRs have benefits, issues include integrating historical records, ensuring data security and integrity, and start-up and maintenance costs. EHRs do not replace in-person communication between providers and patients, which remains important.
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Electronic Health
Record
Electronic Health Record
•Why?
•With an increasing number of populations together with
the past face technology , an immediate process should
be incorporated in the medical health system to facilitate
the daily activity of the health officer.
•Also known as electronic medical records or computerized
patient records
•Found more useful when the number of data being
processed are highly prioritized and / or a large data are
being stored
•Provides the ability to manage health information using
modern information techniques that are impossible to apply to
paper record keeping.
Electronic Health Record
•Its use has the potential to dramatically change how both
individuals and society view health care
•A repository of electronically sustained information and data
of every patient transactions, health condition, medical
records, and other pertinent information necessary for
computer-based health information system
•Usually accessed on a computer, often over a computer
networks or system
•Made up of electronic medical records (EMR) from the
different departments such as Nurse Department, Laboratory,
pharmacology, etc
Electronic Health Record
•Adds information management tools to provide clinical
reminders and alerts, linkages with knowledge sources for
health care decision support, and analysis of aggregate data
both for care management and for research
•Integrates all the information and data of all system, it does
not support statistical information system
•Data can be entered electronically through a dedicated
computer in a standard format that simplifies the input
process, the data and information can be displayed to desired
formats suitable for the interpretation of the users
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Types of Data Stored in EHR
•Patient profile
•Results of medical examination
•Medical history
•Development of health condition and status
•Results of laboratory test
•Information about allergies, illness, immunization, disorder,
diseases, etc
•Medicine taken and its compatibility with drug interaction
•Records of appointments
•Billing records
Issues in EHR System
•Integration and synchronization of historical records and incoming
records
•Readiness of the patient profile system
•Continuing preservation of data warehouse and its associated
facilities
•Purchasing of computer system, specialized networking and
communication system and sophisticated software
•Preservation of integrity and security of data
•Conversion of historical data into electronic data
•Continuous updating of storage capacity
•Computer system may experience short term crashing, bugs,
virus, etc.
•Start – up costs and software maintenance costs
•Additional manpower to support the computer based process
•Responsibility and ownership of electronic health records
•Data can be altered
•System crashes
Communication with Patients
•Although EHR is one of the most effective ways to increase
quality of service to patient through computer methods, it will
not replace the traditional communication between nurses
and patients and clients and health care providers
•It is important to remember that there is no substitute for face
– to – face interaction, particularly on important issues.
•Should be continuous as part of the day – to – day
processes of a nurse and health care providers.
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