A patient record consists of information related to their history of health information providing information on patient care used for billing and reimbursements for services rendered. Patient record contains pertinent health information that will follow the patient along to provider whom they seek care from. Having accurate health information helps Doctor familiarize themselves with the patient history used to provide care for symptoms present. As indicate by Gartee there are two forms of health information primary and secondary records.
Primary records are obtained first hand through documentation from the patient or a provider. These records containing history of patient complaints, diagnosis, physician orders indicating tests and their results as well as nursing notes. Due to the numerous providers whom the patient would seek treatment their records do consist of a wide variety of facilities documentation and information from treatment. Examples of primary records are physician …show more content…
implementation of the electronic medical record assist with keeping a patient records accurate and prevent duplication of testing or unnecessary protocols. As well as prevent near misses or adverse effects during patient care. In addition to improving financial out by providing accurate documents necessary for reducing costs associated with streamlining billing processes (2009). The health services research conducted a research which indicated that “American quality of care is inconsistent and could be substantially improved (Steinwachs & Hughes, 2008).” Transitioning to EMR will help bring together patient information as well as increasing research abilities through abstracting needed information that can improve the quality of patient care with this information (Steinwachs & Hughes, 2008). In addition to improving the quality of patient care there are still some forms that will normally be in paper form they are known as administrative
Primary records are obtained first hand through documentation from the patient or a provider. These records containing history of patient complaints, diagnosis, physician orders indicating tests and their results as well as nursing notes. Due to the numerous providers whom the patient would seek treatment their records do consist of a wide variety of facilities documentation and information from treatment. Examples of primary records are physician …show more content…
implementation of the electronic medical record assist with keeping a patient records accurate and prevent duplication of testing or unnecessary protocols. As well as prevent near misses or adverse effects during patient care. In addition to improving financial out by providing accurate documents necessary for reducing costs associated with streamlining billing processes (2009). The health services research conducted a research which indicated that “American quality of care is inconsistent and could be substantially improved (Steinwachs & Hughes, 2008).” Transitioning to EMR will help bring together patient information as well as increasing research abilities through abstracting needed information that can improve the quality of patient care with this information (Steinwachs & Hughes, 2008). In addition to improving the quality of patient care there are still some forms that will normally be in paper form they are known as administrative