After studying this chapter you will be able to: List four medical mistakes that will be greatly decreased through the use of EHR; differentiate among electronic medical records, electronic health records, and personal health records; contrast the advantages and disadvantages of electronic health records;...
Chapter 1 - Electronic health records for allied health careers. After studying this chapter, you should be able to: List three reasons why paper-based medical records are no longer adequate, discuss the economic pressures forcing changes in the health care system, describe the role of the government in bringing about changes in the health care system,…
Chapter 2 - Transitioning to an electronic health record and the need for clinical information standards. After studying this chapter, you should be able to: Describe the major strategies for converting paper-based charts to HER; list the four ways of entering live patient data into HER; explain how desktop, laptop, and tablet computers differ;...
Chapter 3 - Electronic health records in the physician office. After studying this chapter, you should be able to: List the five steps of the office visit workflow in a physician office; discuss the advantages of pre-visit scheduling and information collection for patients and office staff; describe the process of electronic check-in;...
Chapter 4 - Electronic health records in the hospital. After studying this chapter, you should be able to: Explain the functions of an EHR in an acute care hospital, list the primary benefits of a hospital HER, list the uses of clinical documentation in an inpatient setting,...
Chapter 2 - Nursing documentation overview. After completing Chapter 2, the students will be able to: Describe the role of documentation in nursing practice; identify the purposes of documentation; identify and explain different types of documentation methods; explain documentation of medication administration using an electronic Medication Administration Record (eMAR); explain the importance and relevance of nursing diagnoses, NOC, and NIC in nursing documentation.
Chapter 5 - Personal health records. After studying this chapter, you should be able to: Explain why consumers are being encouraged to take a more active role in their health care, list five tools that personal health records offer that enable individuals to manage their health care, explain the differences among the four types of personal health records,...
Chapter 6 - The privacy and security of electronic health information. After studying this chapter, you should be able to: Describe the purpose of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA), discuss how the HIPAA Privacy Rule protects patient health information, describe when protected health information can be released without patients’ authorization,…
Chapter 7 - Introduction to practice partner. After studying this chapter, you should be able to: Explain how the use of access levels protects the privacy of information in a patient record, describe the purpose of the dashboard, explain where patient registration information is stored and accessed, explain the function of the Chart Summary,...
Improvements in healthcare delivery in recent years are rooted in the continued industry-wide investment
in information technology and the expanding role of medical informatics. Endeavors to combine
medical science and technology have resulted in a growing knowledge base of techniques and applications
for healthcare delivery and information management in support of patient care, research and education.
Technology is changing the qualifications required to perform both clinical and administrative allied health duties. Students entering the job market today must be familiar with the ways in which technology is used to perform on-the-job tasks. In particular, the understanding of electronic health records is essential. This text integrates the presentation of concepts with the opportunity to gain hands-on experience working with a simulated EHR software, Practice Partner.
Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O).
Stratified medicine relies heavily on data analysis and the amount of medically relevant
data that are available electronically increases dramatically. However, these data are
generated in complex forms and are acquired and recorded in various ways. Incompatibility
among research databases, electronic medical records and laboratory information
management systems is then an issue. The challenge is to organise electronic data and to
make them usable for research.
Over a century ago, with the work of Alexander Graham Bell, the motivation underlying
the first use of the telephone in communication had a health-related origin: a
doctor attempted to be in contact with his deaf mother and sister. Early developments
in electronic patient records took place over 40 years ago through the pioneering
work of Ed Hammond and his interest in community and family medicine. Very
soon, the European Union will be celebrating a 20-year history of co-financing
eHealth research and development initiatives.
This series is directed to Healthcare professionals who are leading the transformation
of health care by using information and knowledge. Historically, the series was
launched in 1988 as Computers in Health Care, to offer a broad range of titles:
some addressed to specific professions such as nursing, medicine, and health
administration; others to special areas of practice such as trauma and radiology; still
other books in the series focused on interdisciplinary issues, such as the computerbased
patient record, electronic health records, and networked Healthcare systems.
Tuyển tập các báo cáo nghiên cứu về y học được đăng trên tạp chí y học Critical Care giúp cho các bạn có thêm kiến thức về ngành y học đề tài:Electronic patient record use during ward rounds: a qualitative study of interaction between medical staff...
This series is directed to healthcare professionals who are leading the
transformation of health care by using information and knowledge to advance
the quality of patient care. Launched in 1988 as Computers in Health Care, the
series offers a broad range of titles: some are addressed to specific professions
such as nursing, medicine, and health administration; others to special areas of practice such as trauma and radiology.
Electronic Medical Records
Our growing reliance on computers and the strength of information technology are playing an increasingly important role in medicine. Laboratory data are accessed almost universally through computers. Many medical centers now have electronic medical records, computerized order entry, and bar-coded tracking of medications. Some of these systems are interactive and provide reminders or warn of potential medical errors. In many ways, the health care system has lagged behind other industries in the adoption of information technology.
The editor would like to take the opportunity to express his sincerely appreciation
to all of the contributors of this book for making it possible to have such a
comprehensive coverage of the most current information in this very dynamic
field, to Dr. Fu for helping with formatting this book, to the support from the
University of Sydney and Hong Kong Polytechnic University, and to the support
from ARC and PolyU/UGC grants.