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Medical Record Keeping[/caption]
Gone are the days of paper documentation of patient visits. Electronic medical records are changing the face of healthcare and making charting easier than ever. Most large healthcare facilities are now switching over to what are known as EMR's (electronic medical records). This is saving healthcare personnel time and improving patient care.
How Electronic Medical Records Work
Electronic medical records or EMR's store all pertinent patient data in the hospital computer system. This system is managed by the hospital IT department. Employees are trained on how to use the software and properly enter patient data.
- Admission - When patients are admitted, the admitting department creates a record with the patients address, insurance and other personal information.
- Patient Visit - The admitting nurse enters any allergies, medications and health conditions. Then any follow-up care is charted during the course of the patient's stay. The system records data such as; vital signs, lab results, doctor's orders and procedures.
- Discharge - The record can be closed out and any teaching information for the patient can be printed out as a handout to the patient. After discharge, the record will be available to nurses and doctors for review.
Having an electronic record for patients gives the healthcare providers easy access to all patient data. This includes; allergies, medications, medical and family history, plus a record of all procedures done during the visit. Keeping these records safe and accessible requires the help of an IT department to assist providers and maintenance the healthcare facilities computer system.
Information Technology and Electronic Medical Records
Healthcare facilities that are using EMR strongly depend on their IT or Information Technology departments to maintain the healthcare records of patients in the main computer system. Day to day functions of the IT department include:
- Maintaining the healthcare facilities mainframe computer system
- Making sure all networks are connected and running correctly
- Clean up of data and patient records
- Training new staff on the operating system
- Answering maintenance and help desk calls
The IT department works very closely with the Health Information Management department. HIM staff are the actual employees that are responsible for managing the data that is put into the computer by healthcare providers. They also code procedures for billing and release records to other providers outside the facility and to the patient's when requested.
Electronic medical records are the wave of the future in streamlining healthcare. This enhances the quality of care and the speed in which it is delivered. Electronic medical records cut costs and greatly reduce paperwork. Whether your career field is actual patient care or support, you will surely encounter electronic medical records in your healthcare career path.