Electronic Health Records and Patients’ Assessment

Introduction

Electronic health records (EHR) refer to the use of IT to store the patients’ data. The need to provide better quality services to patients at an affordable cost has highly contributed to the increased adoption of EHR. Data stored in the electronic version is accessible to all the medical staff in a certain healthcare facility (Coorevits et al., 2013). This paper explores the process of recording patients’ history using the practice fusion. The paper assesses the benefits of adopting HER coupled with how behavioral and psychosocial assessments are performed using the mentioned electronic recording.

Recording patient history and physical assessment findings using electronic health record

The software enables patients to contact their doctors to arrange a visit. During the visit, the doctor may opt to input the patient’s data to the computer using the traditional keyboard. Alternatively, the doctor may use the voice recognition system, which is available in the software, to record the patient as s/he speaks. A healthcare provider could also use the touch screen pen to feed data to the patient’s account electronically. After inputting all the relevant data, the software updates the information automatically to the patient’s account. The doctor may then share such information with other staff in the facility through the Internet (Menachemi & Collum, 2011). Before making prescriptions or ordering a test, a doctor reviews any past treatments given to the patient. The doctor may then refer the patient to the next department for further treatment or administration of drugs without having to write the prescriptions on a paper. Through the patient fusion, a patient can access the information through electronic devices with good Internet connectivity (Hoyte, Adler, Ziesemer, & Palombo, 2013).

Behavioral and/or psychosocial assessments performed and charted using such record

Practice fusion was originally designed as a tool for recording the patients’ data for the general population. In its original version, the software did not consider patients with behavioral problems. However, behavioral health functionality has been added to the software (Bowman, 2013). Using the software to make behavioral or psychosocial assessments involves the application of the psychiatric templates for things like interviews and mental status exams. Anxiety, depression, and substance abuse can be detected through the software. Doctors usually ask patients to take a test provided in the software. Besides, live recording of interviews with patients facilitates the assessment of the clients’ psychosocial and behavioral health information.

Using EHR to improve care

EHR improves the quality of care by minimizing medical errors that often come from inaccurate recording of the patients’ records. Medical errors are among the leading causes of health complications, which cause an increase in the healthcare costs (Ajami, Ketabi, Saghaeiannejad-Isfahani, & Heidari, 2011). In EHR, the patients’ data is recorded accurately and it can be retrieved anytime when needed. The patients’ history is easily retrieved and information about previous treatment availed.

Besides, EHR facilitates evidence-based treatment since it allows nurses to conduct research and store the findings in the electronic devices for future reference. Such information as the patient’s major illnesses, surgeries, allergies, and medications is easily accessible through an electronic problem summary list. The information guides the current treatment leading to better quality treatment.

Another advantage of using EHR is that it is time saving. Information is shared among different departments and it can be used by different personnel contemporaneously. The accessibility of information improves the patients’ training during visits, thus leading to better treatment outcomes (Ajami & Bagheri-Tadi, 2013). Timesaving leads to financial savings through reduced cost of healthcare.

Conclusion

The need to improve the quality of healthcare has facilitated the use of IT to record the patients’ history. Through the practice fusion software, patients can arrange for visits with the doctor online. Each patient’s data is stored and retrieved in the subsequent visits. The electronic records have many benefits ranging from cutting down the healthcare costs to improving the quality of care.

References

Ajami, S., & Bagheri-Tadi, T. (2013). Barriers for Adopting Electronic Health Records (EHRs) by Physicians. Acta Informatica Medica, 21(2), 129-134. Web.

Ajami, S., Ketabi, S., Saghaeiannejad-Isfahani, S., & Heidari, A. (2011). Readiness Assessment of Electronic Health Records Implementation. Acta Informatica Medica, 19, 224-227. Web.

Bowman, S. (2013). Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications. Perspectives in Health Information Management, 10, 1-19. Web.

Coorevits, P., Sundgren, M., Klein, G., Bahr, A., Claerhout, B., Daniel, C.,…& Kalra, D. (2013). Electronic health records: new opportunities for clinical research. Journal of International Medicine, 274(6), 547-560. Web.

Hoyte, R., Adler, K., Ziesemer, B., & Palombo, G. (2013). Evaluating the Usability of a Free Electronic Health Record for Training. Perspectives in Health Information Management, 10, 1-14. Web.

Menachemi, N., & Collum, T. (2011). Benefits and drawbacks of electronic health record systems. Risk Management and Healthcare Policy, 4, ­47-55. Web.