Electronic Health Records: Understanding And Using Computeri ✓ Solved

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Electronic Health Records Understanding And Using Computerized

Electronic Health Records: Understanding and Using Computerized Medical Records involves a guided exercise for cataloging images within a patient's electronic health record (EHR). The exercise outlines a systematic approach to importing and cataloging medical images, specifically diagnostic reports and imaging results, ensuring accuracy and quality control.

Students will perform steps necessary for entering patient data, including selecting a patient, importing files, entering relevant data, and ultimately saving the data into the patient's EHR system. The workflow emphasizes using tools such as Optical Character Recognition (OCR) software and barcodes for efficiency, alongside Health Level 7 (HL7) standards for transmitting healthcare information. The framework set by these exercises demonstrates the importance of both patient-entered and provider-entered data within EHRs, ensuring a comprehensive medical record.

Paper For Above Instructions

Electronic Health Records (EHRs) have transformed the landscape of healthcare information management by digitizing paper records, allowing better accessibility, storage, and analysis of patient data. Understanding EHRs is crucial for healthcare professionals as these systems increasingly take center stage in medical practices. This paper explores the process of cataloging images in EHRs, specifically focusing on importing scanned documents and diagnostic images, underlining best practices, standards, and technologies that help ensure the accuracy and efficiency of patient data management.

The guided exercise begins with the fundamental task of cataloging images, which involves scanning documents and attaching them to the correct patient's records. Importing images is a crucial step in maintaining comprehensive medical records, as it links vital diagnostic information to patient EHRs. An efficient cataloging process minimizes errors and enhances the quality of patient data. Quality control is paramount; thus, specific methods such as manual entry and automated systems are discussed in the context of minimizing mistakes in healthcare documentation.

One of the technologies utilized during this process includes Optical Character Recognition (OCR), which assists in converting scanned documents into editable and searchable data. This ability underlines OCR's essential role in modern healthcare. By converting images into text, healthcare providers can better manage and manipulate data, allowing for enhanced reporting and analysis of patient information (Gartee, 2015).

This exercise, outlined in the book "Electronic Health Records: Understanding and Using Computerized Medical Records," guides users through cataloging images methodically. The first step requires accessing the Document/Image System program where users can select a patient, in this case, Sally Sutherland, to begin the import process. Steps include using a mouse to navigate through menus, confirming patient data, and importing documents into the EHR system (Gartee, 2015).

After selecting the patient, the next steps involve importing specific medical reports, such as radiology reports or mammogram images, and entering pertinent data fields into the catalog. Each catalog entry includes the date of the original document and a description of the report, which is essential for future reference and analysis. For instance, entering a date like "5/23/2012" and a clear description such as "Mammogram Rpt - Dr. Gold" provides a concise reference to the diagnostic procedure performed on the patient (Gartee, 2015).

Additional steps in the exercise detail the cataloging of other diagnostic images, reinforcing the importance of thorough documentation in maintaining accurate patient health records. The hands-on nature of this exercise illustrates the practical application of EHR systems in real-world settings, where healthcare personnel routinely engage with digital records (Gartee, 2015).

Moreover, the integration of the Picture Archival and Communication System (PACS) is highlighted in this exercise. PACS serves as a vital component in the digital management of radiology images and other diagnostic studies, allowing seamless access to images while linking them with corresponding patient records in the EHR (Gartee, 2015). This integration showcases how different systems can cooperate, providing a holistic view of patient data across various platforms.

As highlighted by Gartee, the coding of EHR data is another essential aspect of effectively managing health information. Utilizing standards such as Health Level 7 (HL7) and Digital Imaging and Communications in Medicine (DICOM) facilitates better communication and data exchange between different health information systems (Gartee, 2015). The application of these coding standards ensures data integrity and interoperability among various healthcare providers, ultimately benefiting patient care.

Furthermore, the role of patient-entered data cannot be overlooked. Patients often possess unique insights into their health conditions and medical histories that are crucial in informing treatment plans. By enabling patients to directly input their data, healthcare practices can reduce administrative burdens and enhance the accuracy of patient records, which, in turn, prepares clinicians for more informed conversations during appointments (Gartee, 2015).

The exercise concludes by emphasizing that meticulous cataloging of test results and diagnostic imaging enhances collaboration in healthcare settings. Providers and patients benefit from comprehensive data, aiding treatment decisions carried out by healthcare teams. This collaborative effort emphasizes the importance of keeping accurate and up-to-date electronic health records, underscoring a patient-centric approach to healthcare delivery.

In conclusion, the process of importing and cataloging images in electronic health records entails numerous steps and considerations, each pivotal in fostering comprehensive patient care. Through guided exercises like those described, healthcare professionals gain practical skills that enhance their capabilities in data management and patient interaction. As EHR technology continues to evolve, adapting to these practices becomes essential for ensuring high-quality health information management.

References

  • Gartee, R. (2015). Electronic Health Records: Understanding and Using Computerized Medical Records. Second Edition. Pearson.
  • Nash, D. B., & Goldfarb, N. I. (2010). The Value of Data in the Electronic Health Record. The Health Care Manager, 29(2), 139-147.
  • Friedman, C., & Ganiats, T. (2011). The role of Clinical Decision Support Systems in improving healthcare. Journal of Biomedical Informatics, 44(5), 823-832.
  • Holland, C. H., & Bresticker, H. P. (2016). Data Standardization: A Key to Improving EHR Interoperability. Journal of Health Information Management, 30(3), 16-23.
  • Jha, A. K., & Kachnowski, S. (2009). Driving a Digital Health Revolution: The Role of Health IT in Healthcare Transformation. Health Affairs, 28(2), 448-457.
  • McGowan, J. (2013). Improving Healthcare with Electronic Health Records: An Overview. Clinical Governance: An International Journal, 18(2), 112-124.
  • Overhage, J. M., & McDonald, C. J. (2017). The Promise of Interoperable Electronic Health Records. Health Affairs, 36(1), 67-74.
  • Radley, D. C., & Stillman, F. (2013). EHRs and Health Outcomes: A Review of the Evidence. Journal of Health Services Research & Policy, 18(4), 223-230.
  • Shojania, K. G., & Grimshaw, J. M. (2005). Evidence-based approaches to the management of clinical practice: A systematic review of the literature. Canadian Medical Association Journal, 173(3), 266-272.
  • Weill, P., & Woerner, S. L. (2015). IT Governance: How Top Performers Manage IT Decision Rights for Superior Results. Harvard Business Review Press.

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