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health care, behavioral health care, critical access hospitals, home care, general hospitals, laboratory services, long term care, Medicare and Medicaid, and office-based surgeries (The Joint Commission, 2012).
In the light of the above goals, EHR aids care coordination by different physicians and healthcare providers. Information exchange is enhanced, making it easier for different physicians and providers to effectively follow-up the care history of patients. Secondly, EHR acts as a point of reference. Drug interactions can be monitored through these records, and physicians are kept posted by waiting actions and procedures to be undertaken. The availability of patients and physicians data on the EHR database further enhances accuracy in patient care across all the aforementioned point of interest in National Patient Safety Goals. Finally, over and above providing records of clinical patients’ encounters, EHR interface supports other direct or indirect care-related activities that include but not limited to quality management, outcome reporting and evidence-based decision support (Lohr, 2008).
"Mandatory fields" marks areas in the data entry form where the information sought by that field must be provided. Basically, the data and/or information that goes into a mandatory field are critical, and one that must be accounted for when making the data entry. Characterized by special marks like asterisks and followed by brief explanations that show the field is required, mandatory fields have to be complemented before the data entry form is saved. Failure to this, the system indicates where errors in the form have been committed, thereby improving and correcting medical information captured. This process minimizes or alleviates altogether chances of medical
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This data includes patient’s case history, details about his disease, his medications, demographic data and laboratory reports, any vaccinations and immunizations, billing and 3-D radiology images regarding the disease. An EHR plays a vital role in evidence based treatment and decision-making.
An electric health record (EHR) is the traditional paper chat that was commonly used by clinical officers, but now it has been made digital. Just like the paper chat, it contains all the treatment and medical records regarding a particular patient in a specific practice.
Electronic health record, a system electronic based record keeping in health care institutions, is an example of application of information technology developments that has been incorporated in the health sector to facilitate communication and management of information for operational efficiencies.
EHR ensures a health facility easy access to and use of important data easily and faster during patient appointments. The program can provide effective assessment tools and management processes for pressure ulcer, which would be a dream in a paper-work system (Liang, 2007).
In the past few years, Electronic Health Record systems are playing a significant role in our lives and offer a wide variety of tools for effectively managing healthcare services and operations. In fact, EHR systems are used to keep our personal information regarding healthcare aspects. In case of any medical and healthcare issue this information can be accessed quickly and accurately and an appropriate solution can be suggested.
Due to the latter, clinical care can now be delivered electronically which triggered emergence of such subject as health informatics and "Australia is at the leading edge of these developments" (Yellowlees, Brooks, 1999, 4)
As Coiera writes, "If physiology literally means 'the logic of life', and pathology is 'the logic of disease', then health informatics is the logic of healthcare.
A clinical information system has replaced the traditional paper orders, notes, and records that have been the historic basis for delivering and documenting healthcare clinical services. A CIS collects and organizes data related to the care given to a patient.
In addition, these terminologies distinguish between the motives and practices of nursing and medicine by serving as the professional language applied and understood between both professions.
Using standardized terminologies
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