Electronic Medical Record System

Abstract

The paper describes about the issues of ABC hospital. The ABC hospital has adopted electronic patient database and services due to the management and confidentiality issues. The traditional method led to the mismanagement of the patient's data and loss of data as well. On many occasions, it was observed that many patients were uncomfortable with the database of ABC hospital. They prefer to have a electronic record system as their first priority because it helps the hospital to maintain the health records of their existing patient, and makes the next treatment of the same patient less time consuming, as the doctors do have to carry the entire check up again, as he can simply have a look at the patient's history through his records. To solve these issue proper electronic medical record system it necessary which is described in the following paper.

Electronic Medical Record System

Introduction

The main purpose of the medical record is to keep record of the health staff's observations and assessment of the patient. Any clinician's record contains the history of the patient and physical examination, which are followed by an assessment, diagnosis, and treatment plan. This is done daily in the hospital or in outpatient. The record also contains clinicians' data such as consultants, test results and administrative data. The medical record are maintained in all locations. For example, each physician's office contains records of notes (Ginneken, 2002). The medical record provides documentation of a patient or a test, so that the clinician can get reimbursement by government agency or insurance company . It serves as source of communication between health care staff. The medical record is also a legal record, and provide support in cases of claims of malpractice. It also provides data for research. It has improved the quality of care and provided a basis for quality improvement for health care organizations and payors such as insurance companies. The medical record has taken importance due to the development of managed care, that the care should be cost-effective and justified. The medical record also warns about the drug interactions and the efficacy of tests (Kamadjeu, Tapang, & Moluh, 2005).



Discussion

Electronic Medical Record

Most clinical use hand-recorded material, as most users are familiar with this and it provides ease of recording. However, there are many problems associated with paper medical records. This record is usable only in one place and problem occurs for patients with complex issues, who encounter with various specialists, therapists, nurses, etc. The paper records may be disorganized and fragmented as it moves in different physician offices. Sometimes, pages are added, making the viewing quite difficult. The paper record has missing information. Paper-based record is vulnerable to be assessed by nonprivileged outsiders , which decreases its security. Its duplication requires photocopying, which is also a time consuming process. The paper medical records need to be stored in large places such as Medical Information Bureau and protected by insurance companies for fraud prevention, as it contains the sensitive and confidential ...