Primary Health Record

Improved Essays
Document, document, document is the word of the day for the topic of patient health records. Each and every time a patient is checked in at an ambulatory center, admitted into an acute care facility or has an encounter with a health care professional or support staff there should be a corresponding electronic or hand-written footprint of the meeting with the appropriate accompanying narrative documented into the patient’s health record. This action protects the patient, the care provider and the facility itself.
Therefore, the initial encounter is arguably the most important. This is because the primary health record is established when the patient first starts to share their demographics, health history and current symptoms along with
…show more content…
The secondary health record, which is created not from the patient first-hand, but later by “analyzing, summarizing, or abstracting” data from the primary record, is necessary for insurance claims, patient safety and to assist administration in quality improvement, financial decision making along with other reporting (Gartee, 2011, p. 102). The importance of the initial data being entered timely is accurate and factual is because of its future use and implications from its use in the secondary …show more content…
Health information technology and management (1st ed.). Prentice- Hall
Lassere, M. N., Baker, S., Parle, A., Sara, A., & Johnson, K. R. (2015). Improving quality of care and long-term health outcomes through continuity of care with the use of an electronic or paper patient-held portable health file (COMMUNICATE): study protocol for a randomized controlled trial. Trials, 16(1), 1-16. doi:10.1186/s13063-015-0760-8
O 'Malley, A. S., Draper, K., Gourevitch, R., Cross, D. A., & Scholle, S. H. (2015). Electronic health records and support for primary care teamwork. Journal Of The American Medical Informatics Association, 22(2), 426-434 9p. doi:jamia/ocu029
Sander, R. (2013). Prevention and treatment of acute ischaemic stroke. Nursing Older People, 25(8), 34-39. doi:10.7748/nop2013.10.25.8.34.e438
Tzeng, H., & Yin, C. (2008). Nurses ' solutions to prevent inpatient falls in hospital patient rooms. Nursing Economic$, 26(3), 179-187

Related Documents

  • Improved Essays

    The first reason that electronic health records should be used…

    • 987 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    During every year that the eligible healthcare professional participates in the program they must demonstrate Meaningful Use of a certified electronic health record. To receive this incentive, the provider must document the percentage of visits, diagnoses, prescriptions, immunizations, and other pertinent health information electronically; use the EHR clinical support tools; share patient information; and report quality measures and public health information (Booth, K. A., Whicker, L. G., & Wyman, T. D. 2014). In addition to a financial incentive, other benefits of complying with Meaningful Use guidelines include a reduction in medical errors, improved availability of patient records and data, reminders and alerts, clinical decisions, and e-prescribing/refill automation (Aumula, N., & Sanelli, P. 2012, July…

    • 755 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    (HIT) is highly advanced and been growing year after year. Health information technology offers great promise for improving the quality of care, including reducing medical errors, and lowering administrative costs, (Sipkoff, 2010). The great benefit from (HIT) is the lowering of costs for less paper usage with electronic records and fewer medical errors is a major advantage. More benefits to health technology for patients is (ehr’s) lessen your paperwork, (ehr’s) get your information accurately into the hands of people who need it, help doctors coordinate your care and protect your safety, and reduce unnecessary tests and procedures, (healthit.gov,2013). The tremendous amount of health information technology with the advantages listed, it’s the most highly reliable system for patients and…

    • 1683 Words
    • 7 Pages
    Improved Essays
  • Improved Essays

    HIPAA And Nursing Practice

    • 1098 Words
    • 5 Pages

    1. What heath care policy did you choose? Why did you choose this one? Define the policy and describe the history behind it.…

    • 1098 Words
    • 5 Pages
    Improved Essays
  • Improved Essays

    The Joint Commission standards require that the patient record contain patient- specific information proper to the consideration, treatment, and services provided. Due to the patient records contain clinical/ case information, demographic information, and other information the Medicare Conditions of Participation (CoP) required each hospital to establish a medical record service that has administrative obligation regarding medical records, and the hospital must keep up a medical record must be precisely composed, promptly completed, legitimately files, properly retain, and available. Within the hospital you have to utilize the system of author identification and record maintenance that ensures the integrity of the authentication and ensures…

    • 265 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    Foundation of Knowledge model Discharge Summaries relate to Electronic Health Records Nursing informatics is a specialty involving knowledge and technology. According to McGonigle and Mastrian, The Foundation of Knowledge model is a “framework for examining the dynamic interrelationships among data, information, and knowledge used to meet the needs of health care delivery systems, organizations, patients and nurses” (2015). The Foundation of Knowledge model includes acquired knowledge, disseminated knowledge, processed knowledge and generated knowledge.…

    • 593 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    Meaningful use has greatly impacted healthcare interoperability by implementing certified electronic health records (EHR). With EHR put into act we are now able to view real time information of patients medical history, past and current medications, immunization dates, any diagnoses or allergies, as well as testing and lab reports. It contains all complete and accurate information to give providers access to evidence based tools when making decisions of a patients care. Some EHRs now allow patients to access web portals to view their own health records and even email their doctors. A major contribution to why meaningful use has helped healthcare interoperability is the fact that electronic health records can be accessible to authorized staff…

    • 255 Words
    • 2 Pages
    Decent Essays
  • Superior Essays

    According to Darzi (2014), the introduction of records sharing schemes is already transforming the medical landscape by reducing errors and improving care. Electronic health records are crucial because ACO’s mange the health of the patient, thus requiring patient care records on every patient in the system. Health information technology provides clinicians with accurate and complete information about a patient’s health and reduces the amount of paperwork for patient and physicians. Additionally, electronic records are an essential part of data recording for the physicians to see the past history of each patient. This would allow the health care staff to take data from all the sources and use it specifically to track and manage the patients.…

    • 976 Words
    • 4 Pages
    Superior Essays
  • Improved Essays

    Before the use of electronic health records, there were paper charts. These charts lined large shelves that often filled entire rooms depending on the size of the healthcare practice or hospital. The idea of the electronic health record has been around for several decades plus years (Gartee, 2011). However, it was not until more recent years that the use of the electronic health record has become more widely used within the healthcare industry. In 1991, the Institute of Medicine of the National Academies sponsored various studies and developed reports that ultimately paved the way for the electronic health records that we use today Gartee, 2011).…

    • 280 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    It’s no secret that the business of health care is a BIG business, being 15% of the gross national product. This creates loads of pressure on hospital/facility commanders to properly and sufficiently run and manage their organizations. Having consistent services, quality, keeping up with consumer demands and proper reimbursement is a key to survival. I think we all can agree that having a paper based system has the power to complicate the quality of our services, organization, consistency and reimbursement. From setting a new appointment for an established patient, to properly processing payments, electronic health records (EHR) have the power to store all of our paper based records into one, consistently up-to-date system.…

    • 1118 Words
    • 5 Pages
    Improved Essays
  • Great Essays

    Meaningful Use

    • 1294 Words
    • 6 Pages

    Introduction The Meaningful Use program and its implications has a great impact on nurses. In the overview section, I will discuss the background, requirements, and intent of the Meaningful Use program. In the analysis part, I will discuss the implications of the core criteria. In the recommendations section I will discuss whether or not any additional criteria is needed.…

    • 1294 Words
    • 6 Pages
    Great Essays
  • Improved Essays

    One of the many innovations in health care is Electronic Health Record. This new system is digital, and it replaces handwritten patient's records. EHRs contains "medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results" (HealthIT.gov, 2013). The information can be shared between health care organizations, and health care specialists can see full medical history of new patients. All medical date in one digital record allows doctors to understand patients' medical issues better and treat patients more…

    • 690 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    Summary This article explained the definition, roles, benefits, and data within a personal health record (PHR) and how it can be used by patients and providers. The definition that the authors assign for a PHR is an, “electronic, lifelong resource of health information needed by individuals to make health decisions.” The PHR can be used to ensure that patients take an active role in their health and are educated on their health statuses. In order to create an accurate PHR, all members of the patient’s healthcare process must work together.…

    • 265 Words
    • 2 Pages
    Decent Essays
  • Improved Essays

    Ehr Pros And Cons

    • 216 Words
    • 1 Pages

    Quality of care can be enhanced by communication between physicians through allowing other qualified health providers access to a patient’s medical history rather than having to transfer medical records to another department. Having this right of entry, allows for the provider to give a more in depth assessment of the patient, allowing a quicker diagnosis. In addition, in case of emergency, these records can provide important, life-saving information to emergency care providers. EHRs provide the ability to exchange complete health information about a patient in a short amount of time. Some of the things that an EHR offer is precise up-…

    • 216 Words
    • 1 Pages
    Improved Essays
  • Improved Essays

    AHIMA: A Case Study

    • 338 Words
    • 2 Pages

    Clinical documentation improvement (CDI) is to ensure that clinical documents reflect the scope of services provided to a patient. Clinical documentation is the core to of every patient encounter. Health information management (HIM) professionals are recognizing the need for detailed clinical data for diagnostic and procedural coding, research, and patient safety. Facilities are improving clinical documentation by implementing programs. According to AHIMA (2015) these programs were developed to teach health care professionals what were not taught in medical schools concerning organization of healthcare records and completing documents in a timely manner.…

    • 338 Words
    • 2 Pages
    Improved Essays