Question

Discuss one of the emerging technology issues in Clinical Documentation and the Health Record and discuss whether it should be included in the definition of the legal health record. Your summary should be at least 100-200 words.

Answer 1

Electronic Health records and its issues.

The adoption of technology in the Clinical documentation and health record systems promises a number of substantial benefits like better care and decreased healthcare costs. Along with the benefits serious unintended consequences from the implementation of these systems have emerged. Poor system design and improper use can cause   errors that jeopardize the integrity of the information in the EHR, leading to errors that endanger patient safety or decrease the quality of care. These unintended consequences also may increase fraud and abuse and can have serious legal implications.

The following are the issues related to the use of technology in the Clinical documentation and health record systems

The quality of healthcare across the continuum depends on the integrity, reliability, and accuracy of health information. Adoption of   technology including electronic health records is essential for the transformation of healthcare system into one that is more efficient, safer, and consistently delivers high-quality care.

Despite the promise of electronic health records   in   improving quality of care and patient safety, a growing body of evidence has found potential safety hazards associated with their use. The emergence of electronic documentation   related errors results in data being lost or incorrectly entered, displayed, or transmitted, leading to loss of information integrity.

The primary goal of technology in clinical documentation and health record has reduced the reduction of medical errors but reports of new types of errors that can compromise quality of care and patient safety have emerged. This medical errors could be prevented if automated alerts are activated. Unless this issue is addresses in the definition of health record the problem cannot be solved and the compromise in delivering quality care will be continued.