Medical records are extremely important to the running of any sort of health facility, such as hospitals, doctor offices, or nursing homes. They keep track of the health history of a patient, any new diagnoses, any treatment plan that has been prescribed, medications that a patient takes or has taken in the past, allergies that a patient has, etc. All of this used to be documented on paper. When I was working in a nursing home in 2004, all of our records were paper based. We needed to document everything that we did with our patients.
If we checked on our patient at all, even if we didn’t actively do anything in their room, we needed to document this. This ensures that we aren’t ignoring the needs of our patients. Since patients need to be checked on very regularly, a lot of space can be taken up using paper records. Especially since in most states, physical records need to be a kept for a minimum of seven years. It is also more difficult for healthcare professionals in different locations to read paper records of a certain patient. A lot of copying and faxing is required to accomplish this.
Electronic Medical Records (EMR) allows the healthcare professional to be more organized and allows them to more easily keep up to date about their patient. If there is something in particular that they need to find out about their patient, it is more readily available with EMR technology. They no longer need to sift through useless information in order to read the one piece of information that they need.
In most hospitals, a computer is placed in every patient’s room so that medical errors are reduced. Every time a medication is given or a treatment done, the patient’s name-band needs to be scanned so that it is ensured that they are receiving the right medication with the right dose at the right time by the right route. Having a computer right next to you when you check all of these decreases medical errors in the hospital system. EMR also ensures patient confidentiality. Only the people directly involved with the care of a patient can read that patient’s medical record.
Log ins are password protected so unless a healthcare provider gives someone their password, they can’t get in to check on the status of a patient. EMR is a very good system that is readily becoming more widespread throughout our medical system.
Prime Clinical Systems (http://www.primeclinical.com/) designs and installs EMR systems that are easy to use and easily customized to the individual EMR requirements of individual medical practices and professionals.
The Centers for Medicare and Medicaid Services (CMS) issued two reminders recently that physicians must be working constantly to maintain compliance with the Medicare quality reporting programs. The current regulations call for adjustment of the fees paid to physicians for services to Medicare patients based on annual measurement of the physicians’ performance under quality and cost metrics. Radiologists must focus on their quality measures because the system assigns them to an Average Cost pool by default since they have little or no control over this factor.