Implementation of Patient information and data

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[Date Submitted]Implementation of Patient information and data

Introduction

The need to record the information about a patient is considered an old and important problem in medicine. Progress in this direction depends on the possibility of having adequate technical support. This is how the advent of writing and the role allowed collecting and storing as written records this data, allowing they faced when necessary. This conception has changed over time, as they have increased the data collected and available technology has changed. Electronic medical records as a hospital clinical information technology in the core, replacing the traditional paper medical records, medical records that retains the advantages of traditional, but also with many of its features. Owing to this fact the implementation of electronic medical record (EMR) has become an inevitable trend (Paul, 2003).

Discussion

The application of computer technology acquisition, processing, transmission and storage of medical writing process real-time information, explore medical writing timeliness of online control, strengthen the management of medical quality, supporting clinicians prevent medical defects and to improve the quality of the medical aspects. The system also provides a built-in variables in the medical record demonstration (Built-in Variable) measures, these variables include the patient's natural attributes, such as: name, sex, age, and other information, also of patient information, such as: patient number, visiting departments, treatment time, and whether the emergency, hospital number, number of hospitalizations, admission date, discharge date, length of stay, purpose of the admission department admission ward residency, the responsibility of nurses, the final diagnosis, allergy drugs (Pare, et al. 1997). When the built-in variables included in the medical record demonstration and references to medical records demonstration, the system will contains a built-in variables automatically replaced with the current patient information, in order to ensure the introduction of the medical records of text does not comply with the current patient's condition does not appear description (Ballantine, 2008).

Implementation

Despite these obvious advantages, this implementation is complex anywhere in the world; both for economic and organizational reasons (need for reconciliation between the different sectors of public health). One can argue that urges the implementation of electronic health records for all the benefits it offers (Ludwick and Doucette 2009). The electronic health records have dedicated almost exclusively to work in this direction and have described five levels to its full and satisfactory, they will explain briefly:

Level 1: Automated Medical Record

At this level are still required based medical records papers (although 50% of this information is generated and stored in a computer) (Cacey, et al. 1997). It is still in paper format, but is computerized to the point where specific automated processes can be conducted. Currently some of the functions performed at this level are: 

Input / Output / Transfer of patients.

Accounting and clinical patient information.

Department's data (laboratory, radiology, pharmacy, etc.).

Supplementary orders and results.

None of these systems are interoperable, not meeting the definition of CBPR and are unable to meet the doctor's file system, as they do is go parallel to it.

Level 2: Computerized Medical Record System

Medical records at this level are ...