PURPOSE The information contained in the medical record allows nurses and doctors to determine the patient’s medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient’s care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
By making a computerized system for a medical record, nurses and doctors can easily determine if the patients has already have a record into that hospital . We are proposing a computerized medical system to lessen the work of those assistant desk secretary . The modern hospital is a storehouse of technology and training unmatched in human society. These lifesaving institutions are often the biggest employer in town, making them – justifiably – the pride of their communities. An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.
The Essay on Medical Ethics Patient Care Physician
The medical profession has been around since the beginning of mankind. It most likely started with women who were warm-natured and nurturing from tribes. Amazingly, we have advanced all the way to professional physicians and many other careers in the field of medicine. Although not actual laws, medical ethics are strict guidelines that most professionals follow. Health professionals most follow ...
Benefits of Electronic Medical Records An EMR is more beneficial than paper records because it allows providers to:
Track data over time Identify patients who are due for preventive visits and screenings Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings Improve overall quality of care in a practice
The information stored in EMRs is not easily shared with providers outside of a practice. A patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.
Differences between Electronic Medical Records and Electronic Health Records An EMR contains the standard medical and clinical data gathered in one provider’s office. Electronic health records (EHRs) go beyond the data collected in the provider’s office and include a more comprehensive patient history.
For example, EHRs are designed to contain and share information from all providers involved in a patient’s care. EHR data can be created, managed, and consulted by authorized providers and staff from across more than one health care organization.
Unlike EMRs, EHRs also allow a patient’s health record to move with them—to other health care providers, specialists, hospitals, nursing homes, and even across states.
For more information about electronic medical records and the differences between EMR vs EHR, please visit the Health IT Buzz Blog.
