How Do Health Care Facilities Use Electronic or Computerized Medical Records?
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Communication
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Electronic medical records are becoming an essential tool in hospitals, medical practices and other health care facilities. They offer a consistent method for open communication among physicians, nurses, labs and other clinical staff without relying on handwritten notes stored in single-location paper records. Patient information can be accessed from multiple locations with password-protected security, and doctors' orders can be queued in sequence to match the importance of the procedure to patient care. For example, certain lab tests might be ordered "stat" for quick results while other lab studies can be deferred to a later time. The computerized "stat" order will appear at the top of the laboratory's to-do list automatically. Electronic medical records hold the promise of streamlining communications and improving the consistency of patient care, which can enable health care facilities to function more efficiently and effectively.
Compliance
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Health care facilities are highly regulated by state and federal health authorities to protect the public interest and maintain minimum standards of care. Hospitals, nursing homes and physician practices must comply with legal expectations surrounding all aspects of patient care. They must comply with laws about documenting every service provided, properly coding each diagnosis and medical procedure for billing purposes, following evidence-based protocols and protecting patient information from those outside the health care system. The patient care documentation also provides the foundation for legal defense when the facility faces a challenge. The adoption of electronic medical records systems has risen, in part, in response to the need to comply with legal requirements. They can be vital tools for protecting patient safety.
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Quality Improvement
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Electronic medical records contain a vast array of information that can be analyzed and monitored in digital form much more readily than paper records. Health care facility officials review the records regularly for compliance with all regulations and medical protocols, to monitor trends in resource usage and patient care patterns and to look for ways to improve patient care throughout the facility. They may focus on patients that come with particular diagnoses to evaluate how they can shorten their time in the facility and achieve better results. For example, patients admitted to a hospital with a diagnosis of asthma might be followed over time to make sure they are not readmitted for the same condition in a short time, indicating a weakness in the treatment protocol the first time around. Medical records reviewers will report the results of their study back to the clinical teams so they can improve the protocols and raise their facility's standards of care.
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