University of Phoenix Material
Understanding Electronic Health Records
Write each term’s definition as used in health care. You must define the term in your own words; do not simply copy the definition from a textbook or other source.
Provide an explanation that illustrates the purpose or importance of the identifiedterm as it relates to Electronic Health Records.
Cite at least 3 peer-reviewed, scholarly, or similar references.
| Term | Definition in your own words (45 to 90 words). | Explain the purpose and importance of the term to Electronic Health Records (45 to 90 words). |
| Technology | ||
| Meaningful Use | Relates to the act of medical practice whereby medical data on a patient’s medical diagnostics have been tabulated to synthesize their transfer to a different healthcare institution, the health insurer to enable the expense through which the prescribed treatment is scheduled through electronic health record references. | It enables safety and the efficiency of healthcare and also minimizes health risks, meaningful use also enables individuals to save on cost and finally it ensures privacy and the security of health information. |
| Health Information Exchange | Refers to all the applicable routines involved in the acquisition of health information. Such involve the public relations; patients, the managerial team, the Medicare team. | The information gathered in relation to this concept addresses the importance of in-corporation of technology systems in the field of Medicare to relay information from different departmental heads and operands within the field. |
| Clinical | ||
| Patient Problem (Concern) | Describes the obviate medical implications accrued by a health practioner in accordance to probing the patients symptoms to help in the judgment relation of the ailment that they may be suffering from. Patients’ problem are at most times similarly related in terms of symptoms. | Electronic health records aid ,through different programmed key cards on tabs about diseases and their symptoms to easily present the possible outcome of the patient problem according to the suggestions once they are keyed in if computerized systems are used. |
| Nursing Assessment | Involves the gradual determination through imposed methodologies to acquire detailed clues on a medical problem. | Assessment is done to ascertain the most possible ailment for proper medical treatment administration .Information is obtained through cues such as auscultation percussion, inspection and palpation to determine the main threshold problem. The detailed conclusions can then be analyzed with help from previous electronic health records. |
| Physical Exam (Patient History, Review of Symptoms, Allergies) | Refers to the physical techniques implemented in the objective of clarifying the possible cause of a health related issue of an individual. | This involves X-rays, blood tests and review of the previous patient history to enable fast and efficient services are relayed. The info is then, through electronic health records integrated and a diagnosis provoked. |
| Diagnosis | Refers to the identification and determination of an illness. | In liaison with the collected data of symptoms, for a conclusion to be invoked on what treatments to administer electronic health records are necessarily reviewed |
| Procedure Preformed | Deliberates the steps infused to encompass and determine the faster medical option to be designated given the complex cognitive deciphered to be the illness cause. | It is related to electronic health record since the history of the drugs used are used to observe if there are impacts and whether or not fit to be used next time. |
| Prognosis | Refers to medical term used to outline the forecasted futuristic predicaments of an illness, the probability of a patient to pull through the treatment and the likelihood they do not. | It enhances the effectiveness of electronic health records to monitor and psychological guide the patient on the expected outcomes. |
| Discharge Plan (E-prescribing) | Refers to the aftermath expected regulations through monitoring the concurrent treatment prescriptions given to a patient about how best to coerce the re-occurrence of the illness. | Electronic health records are a proficient means to track the patterns of an outward patients for complete recovery. |
| Patient Education | Refers to the awareness exercise imparted on a patient with relation of the illness they suffer from and ostensibly clarify the cons that led to the result of the illness. | They impact change in the electronic health records to help create familiarity of the disease to the patient. |
| Administration | ||
| Patient Demographic | Refers to the population distribution in respect to their ages, ailments and other issues. | This concept aids in the budgeting and identifying the level of professional requirement in different specialties’ |
| Insurance Information | Identifies the patient to a known health fund and whether or not the patient’s medical expenses are viable for coverage through their hospital funds in lieu of cash payment. | This enables the electronic health records to have the correct data of the patient with the previous data of the insurance and what the patient has been insured against. |
| Advanced directives | Refers to any latter obligatory propositions that are considered feasible in the cure treatment of an illness prescribed by a professional of a medical institute due to a shortcoming of the treatment aid as at the moment of treatment administration. This are the altruisms that are proficient. | Electronic health records are therefore able to note that such ailments are not able to be tended to in the specified ailment thus incase of such case report referrals are immediately initiated. |
References:
Carpenito-Moyet., L. J. (2008.). Nursing Diagnosis Application to Clinical Practice. Lippincott Williams and Winkins.
Carter., J. H. (2008.). Electronic Health Records. ACIP Press.
Kelley., T. (2016). Electronic Health Records for Quality Nursing and Health Care. DEStech publications.
Sinha., P. K., Sunder., G., Bendale., P., Mantri., M., & Dande., A. (2012.). Electronic Health Record. Wiley.
Skolink., N. S. (2010.). Electronic Medical Records. Springer .
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