In: Nursing
ELECTRONIC HEALTH RECORD
Electronic health record are the types of record in which patient information is saved in computer or in digital form, so that it can accessible from any department in the hospital. Information include patient identification, diagnosis, treatment plan, lab report, radiology report, follow up, visit plan etc.
Previously health record was maintaining on the paper and some hospital use paper documentation in some countries but electronic health record is means for reliable, accurate and prolonged type of documentation. It has various significance
SIGNIFICANCE OF EMR
- Patient information can be seen from any department (radiology, nursing, biochemistry)
- Help in maintenance of single patient record
- These data help in the epidemiology for prevalence and incidence of specific diseases
- Help in the study of disease
- It also makes the research easier than the paper health record
- It helps in the maintenance of patient history whenever he or she visit to doctor, doctor don’t have to look after for paper of health record, he just has to open electronic data of patient.
- It helps in the organization of patient data in one portal.
- Help In identifying the drug interaction warning at the time of ordering and high dose warning also.
- It reduces the paper pen expense, more accurate and efficient.
- It improves the care provider and staff job satisfaction.
- Continuity of care is maintained.
- It supports interaction which other system like claim and insurance etc.
- EMR help in the reminder of many things like immunization date of child, follow visit of patient, surgery date, drug change date etc.
- It provides assistance to financial and administrative coding for structured data.
- It helps in maintenance of treatment relationship with patient and ability of manage list of patients assigned to healthcare professional.
- It has all continuous information of patient for coding (ICD, CPT, HCPCSC).
- Help in demonstration of care and easier to adhere with regulation.
- Help for implication of evidence based clinical guidelines.
- It supports work flow management.
- It has facility of alert when to collect blood, Blood glucose checking, specimen taking or culture etc.
- Patient can retrieve his/her information during referral or admitted in tertiary hospital with proper format and ongoing treatment plan.
- It reduces the chances of error(dosage error or medication error etc.) which was previously occur be due to overwriting or bad writing written on the paper.
HEALTH IT (INFORMATION TECHNOLOGY) DEPATMENT
Hospital IT department is crucial department in the hospital, It help in storage, retrieve, and transferring of information electronically. It has a ability to maintain, improve the quality of care and effectual care. It has software which support various activity in the hospital setup. IT department support EMR in various ways
- It has software which help in drug calculation, IV pump rate maintenance, ECG machine on software etc.
- Help in billing and registration of patient.
- Help in electronic medication prescription.
- Support clinical orders, lab result (comparison with normal value), pharmacy system.
- Help in maintenance of hospital inventory, patient record and parole system.
- Reduces the cost and time of the hospital.
- It provides website patient services like online doctor visit, e- prescription etc.
- Reduces the chances of error.
- It also supports physician for diagnosis.
- Keep record for studies. (national or international)
- It supports legal requirement, medical researches, evaluating prognosis, patient counselling.
- Help in making quick and efficient decision, analysis of cost expenditure and quality of care
APART FROM EMR it help in finance management (demand and supply ) and salary making , health worker attendance maintenance, cash flow management etc.
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