This exposition starts by looking at the history and importance of record keeping in any industry. It goes further to share why the act of record keeping is always very important and also introduces the concept of electronic health record systems. Numerous advantages, including the reduction of error by practitioners, are discussed. We also look at the different levels that the system can be incorporated in the efforts to improve on the quality of health that patients are exposed. It is made clear that technology has allowed for the medical arena to be more efficient, and ultimately improve on the quality of the healthcare that we receive. We have come to a point in time where the only viable option is embracing new medical technology including electronic health records if we wish to enjoy higher quality healthcare.
Objectives and relevance to nursing
Nurses are directly charged with the responsibility of offering patients the best care to their abilities. This includes ensuring that they are comfortable, and everything is done with the least error possible. Record keeping stands out as a major part and parcel of any efficient system. Medical practitioners, including nurse, have used files and charts in the past to keep records. Today, technology has allowed us to go digital, synchronizing a wide range of data and hence providing information for use by medical practitioners. There are numerous advantages of adopting such a system, including cost, time and effort ( Rao, 2013). This paper bids to look at these aspects in depth while linking them to the benefits that can be felt by the patients, about quality health care.
General discussion of topic/issue/construct
Over the years, we have grown to come to terms with the fact that everything in the world is always changing. The way we handled things in the past is not the same way we expect to handle the same in the future. Change has managed to be among the most constant elements in our day to day lives. With every passing day, we are introduced to new technology. In this case, technology can be defined as an innovative way of handling things using lesser time and resources. It gives us a platform to achieve more over a lesser period (Tulchinsky, 2014). Technology has always evolved in our day to day world, allowing us to be more efficient in everything that we engage. We are now able to use lesser energy to get better results.
One of the changes that we have come to recognize is linked to record keeping. In any field that we operate in, be it engineering, sports, and even the medical field, records are vital to ensuring continuous efficiency. In the olden days, people used numerous methods to ensure that records were kept, allowing them to refer to them whenever needed. People depended on charts, notes and even simple arithmetic in compiling records (Kamath, 2012). The same can be said about record keeping in the medical field.
Over the last few decades, we have come to see numerous changes in the way we keep records. In the medical arena, the importance of keeping records can never be underestimated. It could be stated that these records can be the only difference between life and death, and in many cases, they are always treated with caution. Even in the medical field, practitioners depended on charts and notes for record keeping. It is true to say that as much as practitioners attend to numerous patients on a daily basis, each and every one of them come with unique problems and hence deserve to be treated with caution. Records are a great source of medical history hence, a practitioner can use that as a point of reference when continuing treatment. It is vital to have accurate records being that any misguided information can cause avoidable damage to a patient. Today, it is not only the patient that can find themselves in a predicament, but rather the practitioners too. Doctors, nurses and even surgeons can easily lose their licenses for operations when they have been found guilty of offering the wrong kind of services. Record keeping helps towards ensuring that patients are at fewer risks and practitioners are able to perform at their best.
Electronic health record system is among some of the innovations that have contributed immensely towards making the medical practice much safer and productive. This is a step from the old ways of record keeping where people relied on chats, templates and handed written notes in a bid to keep records. Electronic record keeping ushers in a digital form of record keeping. There are numerous advantages that come with having records sourced for, recorded and stored in digital format. The electronic health record system has many features that have contributed towards its accelerated levels of adaptation in the medical realm. According to In (2014), these system allows for all record inputs to be on a real-time basis. What this means is that practitioners, from different points, once logged in to the system are able to view the latest updates made to a system, almost immediately. The electronic health records are known to be patient-centered in nature. This only means that the system is primarily designed to hold information regarding patients only. As much as other secondary information can be uploaded into the record keeping system, patients records still hold a bigger chunk of the entire system.
Notably, electronic health record systems come with a provision to be connected to the internet. At specific health centers, the connection can be customized to be visible only to the people at the center. One of the key features that make the system very efficient and private is linked to the fact that there is hierarchy put in place, hence, not everyone logged in can be able to view all records. Doctors, surgeons, pediatricians can be expected to view more information about a patient in comparison to a nurse assistant. In some cases, not even surgeons can be able to view specific files in fields that they are not connected. Authorities including the head of departments or even divisions are among the personnel who can have access to every record kept. Security and privacy still stand out to me among the most important elements in medical record keeping.
Quality can be defined as the ability to offer more than what if expected. Record keeping gives room for reference whenever needed, but the electronic health record system improves on these basic. Quality in healthcare provision can be achieved being that apart from simply keeping records by practitioners, the scope can be broadened by the system. Instead of simply keeping medical history records and treatment history, algorithms can be incorporated in the system to broaden the view, even allowing doctors to be able to remind patients of future appointments. The system can go as far as keeping records of both current and future medical requirements. This can take the form of synchronizing treatment plans with immunization dates, medical history and even records of patients allergies (Talasila, 2012). The system allows for improved quality of patient care being that different departments can fully utilize the records in a bid to establish better workflow, avoiding making clashing appointments.
Improved diagnostics and patient outcome
Electronic health record system allows healthcare providers to have full access to up-to-date data on a patient. With this, they are put in a better position to improve on the quality of the service that they are providing being that the information they have is also accurate. Accuracy in record keeping can be exploited as a key tool during the diagnosis process. Doctors improve on the quality of their practice being that they can reduce, if not eliminate any chance of error during diagnostics. The patient is placed in better hands, borrowing from the fact that the electronic health record system allows for the doctors to have information about them at their finger tips.
Markar(2012) is among the researchers who have gone deeper to gain a full understanding of the benefits that come with the proper utilization of the electronic health record system. According to his literature, he carried out a survey and found out that 94% of doctors interviewed praised the introduction of electronic health record keeping systems. The practitioners are said to quote the fact that they are always able to access the information they want, whenever they need, almost effortlessly. This is a view shared by Kamath (2012) that the system is much more beneficial to the medical realm, much more than we can imagine. In his research on the benefits that come with the implementation of the system, he established that 88% of the practitioners interviewed quoted to have a positive attitude towards the electronic health record system. Notably, the people who still seem to benefit the most are the patients. Doctors can work on more patients efficiently, saving them more time and energy. Patients are better off being attended to by practitioners who have all their records and are not tired as a result of manually looking for the same records in a pile of files. 75% of doctors who use the electronic health record system confirmed that the system has allowed them to be better in how they handle their patients (Kamar, 2012).
Time is among the most important factors in the medical scene. For a patient in a critical position, every minute counts (Bali, 2013). The quality of healthcare provided is significantly improved being that apart from merely storing data, it can be manipulated to form information that can be key during treatment. The electronic health record system can be programmed to compute every data that is feed into the system. The system can be set to be able to alert practitioners whenever any conflicting decisions are made. An example would be that a patient is allergic to a specific component of a drug. When the information is entered in the system, doctors in future can be alerted whenever they try to prescribe the particular drug to the patient. In this case, quality is met being that the patients health is put first by the mere program that reduces room for error.
In a life and death situation, proper treatment can be key to avoiding the latter. In a typical sense, hospital staff, for example, a family doctor can enter specific information regarding a patient in the system. The electronic health record platform allows for diverse people to be able to access this information. The reality is that we can always find ourselves being brought in through the emergency section. One of the benefits of the system is that even the medics can be able to access the system, evaluate ones medical history, including records of allergies and complication and hence better serving their patients in the time of need (England, 2012). In the long run, these elements work together towards improving on the overall quality of care that patients are exposed.
The benefits of having an electronic health record system go further that directly dealing with the patient. The system can easily be used to improve on the way the whole system is being run. In a typical sense, the electronic health record system can be used by managers to monitor patients from a holistic point of view, rather than having to look at specific patients. Patterns and trends can be evaluated, revealing trends in patient characteristics. The reports developed can be used to identify red flags within the system in a particular system. An example would be identifying the time that most patients come in for treatment. Through the system, we can have better knowledge of the development of particular diseases and illnesses. According to In (2014), there are some infections that can be classified as outbreaks is more than four people are reported to have...
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