Initial Intake Assessment Paper

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

In a general medical record a patient is entitled to a copy of his or her record, the only thing they would have to do

Patient's name, address, telephone number, and date of birth. (In the case of a minor child, you will also need the name of the parent or guardian requesting the appointment).

My clinical site utilizes an electronic medical record. This system is integrated with the nearby hospital system. Information is placed directly into the patients’ electronic medical record (EMR). Details related to the history and physical are entered as information is obtained during each visit. Behavior and psychosocial details get recorded in a standardized template such as a SOAP note.

Once established many issues arise, for example, any outside doctors need to be approved prior to the veterans visit, and this creates, even more, problems because it was too much “red tape” on the process. The other issue was that Congress estimated that it was too costly. To replace the veteran's choice VA and Congress decided to implement “MyhealtheVet”, the program permits veterans to search a variety of methods to improve their health and gain a better understanding of their overall health status. The program provides veterans with a number of tools and resources to evaluate, monitor and access medical information from any location that internet is available. The program directly connects veterans to their health care providers to make sure that they are getting the best medical assistance possible. Sometimes, the only thing that the veteran needs is a prescription refill, before they have to wait for a doctor’s appointment just to do that, now using My HealtheVet they send a message directly to the doctor and he or she let the pharmacy know of the patient needs. The veterans can pick up the prescription at the pharmacy or the prescription can be mailed directly to their homes (United States Department of Veterans Affairs,

Once the Authorization for the Use and Disclosure of Protected Health Information is complete, the medical record assistant will retrieve the request from a system called, Fax Finder. It is an electronically fax, that is placed on a computer desk top, and retrieves the request forms daily. The request forms are sent from physician offices, patients, and legal matters. After retrieving the request for example, a doctor’s office is requesting records that state the patient is cleared to return to work, after successfully completing a heart stint, the medical record assistant, will then access, Greenway (electronic medical record), and input the patients first and last name, and date of birth. Once the office note is located that states the patient can return to work as normal, it is then electronically faxed to the doctor’s office that was requesting the

Patient is due for her influenza and pneumococcal vaccine. Patient educated on both vaccines especially the pneumococcal vaccine in regards to her having a chronic condition Diabetes. Patient also given literature, patient at this time declines for personal reasons. Patient cervical cancer screening is not due until 12/6/2015. Patient also due for breast cancer screening, order written, patient will call to set up appointment. Patient up to date on tetanus, next vaccination is 1/1/2016

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

- Patient's name, address, phone number, birthdate, reason for appointment, and if the patient is enrolled in an Insurance

The electronic medical record (EMR) is basicly the patient’s medical record from an individual medical practice, hospital and or pharmacy. It does not go outside from the facility where it was created. Whereas an electronic health record (EHR) is the patient’s electronic medical record from multiple medical practices combined into one database. The electronic health record can be view outside from where it was originally created. The total practice management system is a software category that handles all the day-to-day operations of the medical practice.

Prepared documents for the meeting. Sorted and filed by discharge ready for long term patient. Assign and billed, filling a chart order and photo. Perform duties in human resources, organized account payable files, and employment documents. Focused on filing and sorting medical records. Improve business skills in communication, know-how, knowledgeable, teamwork, and communication. Focused on teamwork with Health Colorado. Forwarded bills

How many of the medical facilities do you see out there that use a paper medical record system? Do you ever wonder if there is a better way, than to fill out all that paperwork, and wait for a phone call back for missing documentation on one patient’s record? There is a better answer, and we are going to talk about it in this paper. It is called an EHR. There will be the pros and cons of both an EHR, and paper Medical Records.

For as long as any of us can really remember, paper based medical records have been the way to go. Sadly if changes had to be made to the files then the files would need to be physically taken out of storage and then returned after. More times than not patients will have more than one health care provider and in this case, the patient files are not necessarily being successfully shared among them due to the fact that the files are tangible. Fortunately the implementation of Electronic Medical Record (EMR) system is the answer to increasing efficiency and reducing the need for storage. The EMR allows the medical records to be retrieved and accessed by any of the health care professionals that need the information to help a patient. Implementing an EMR would have improved diagnosis and treatments, significantly reduce errors found within personal health records, and improve the speed of care and decision making responses from assigned medical professionals. As with everything there are always cons as well as the pros. The unfortunate cons of an EMR are the technological side. It may be difficult to teach all of the people who will be using it how to use the EMR and more importantly getting a majority of people on board with it. After weighing out the pros and cons, there are series of steps that are conducted through stages otherwise known as phases. EMR implementation require making sure that the organization is ready for the commitment, making an outline, creating a system

An Electronic Health record is a computerized collection of patient health data. It is a way to organize and store patient information electronically. EHR is not limited to doctor’s notes; it is including medical and family illness history, test results, health insurance information, billing records. EHR can be managed, created by authorized providers and staff members from different facilities. EHR can be transferred with the patient to different hospitals, facilities even across a

Electronic health records: This type of clinical data resides generally at the point of care such as a hospital or office clinic. Best known as the Electronic Health Record “EHR”, and opened to healthcare providers, it has a restricted access to