National American University
This paper is about the forms and design of the electronic health record. How I might change or add to the form and the guidelines of such forms. There are accreditation standards as well as state and federal laws to uphold and to be considered when creating these forms for the committee to review. All information must be timely and current as well as unique to each record.
Assignment 4: Forms and the EHR
I will cover paper as well as electronic health records in this paper. What can be done to implement the change from paper to electronic more smoothly, preventing duplicate records while keeping all data current and updated in every aspect possible. Also formatting and design that is user friendly as well as the information recorded current with federal and state laws. Finally, the Slocomb software and how it is useful in healthcare.
There are two basic formats. Paper or electronic for recording data in the healthcare industry. The foundation of the electronic health record is defined by data elements. The paper record unfortunately lacks flexibility for individual customization.
Three major types
The three major types of paper based records are source oriented, problem oriented, and integrated health records. Problem oriented are better suited to the patient and the end user of the record. Key characteristic of this format is an itemized list of the patients past and present social, psychological, and medical problems, each identified with a unique number. It also contains a data base, initial care plan, and progress notes. SOAP is a common form of this.
Source oriented documents are grouped together in the Source oriented form. This is done by their point of origin. While Integrated contains documentation from various sources intermingled and follows strict chronological order. (Date) this makes it easy to follow the diagnosis and treatment plan. (P. 126) the problem with the integrated style is that is difficult to follow any one specific type of healthcare professional. (p. 126)
The IOM developed uniformity in EHR’s by identifying 8 core functions. They are:
1.) Health information and data- patient data using defined data sets and interfaces with related medical treatment and diagnostic reporting systems.
2.) Results management- electronic reporting of tests, consultations, and related patient consents.
3.) Order entry and management- electronic order entry with allergy interaction and lab report interfaces.
4.) Decision support- reminders, prompts, diagnosis, and disease management information, adverse event, disease outbreak, and bioterrorism tracking.
5.) Electronic communication