Understanding Electronic Health Records

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 identified term 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).
Meaningful Use Meaningful use is using Electronic Health Records in a way that substantially improves the delivery of healthcare. This can be done using Electronic Health Records in a meaningful way, such as ePrescribing, Using Electronic Health Records technology to electronically exchange health information in order to improve the quality of healthcare, using Electronic Health Records technology to report clinical quality and other measures interact with patients, and keep patients medical information private. Healthcare providers who demonstrate that they are using an EHR in a measurable way may qualify for significant federal financial incentives. Meaningful use is important because it guarantees specific safeguards. It protects the confidentiality of patient information, makes sure the data is secure, provides a standard way of entering information so it can be shared between providers and ensures a consistent way of recording data. The purpose of meaningful use is to be sure the ARRA money was spent on software that doctors actually end up using. Everyone has then taken meaningful use whatever direction they want.
Health Information Exchange Health information technology is the is the electronic development of health-related data and it has the capability to send and get secure data electronically between care suppliers to support composed care such as such as laboratory instructions and results, discharge summaries, or patient referrals directly to another health care professional. According to “Himss.org” (2014) “The purpose of health information technology is to facilitate access to, and retrieval of, clinical data to provide safe, timely, efficient, effective, equitable and patient-centered care” (Himss). Health information technology is important because it can help patients get better care in a timely manner.
Patient Problem (Concern) Patient problem (Concern) is basically the health reasons why the patient makes an appointment to their physician. Most patient complaints are due to symptoms that the patient is having or anything else the patient is being affected by. It can also be a question concerning a medication. Patient problems (Concern) are important because the physician needs to know what the problem is in order to diagnose the patient correctly. Depending on the symptoms the physician can make other decision regarding what test need to be done or if a medication is needed in order for the patient to feel better.
Nursing Assessment A nurse’s assessment is the first step in the nurse’s process. It is the gathering of the patient’s information. This information includes physiological data, psychological, sociocultural, spiritual, economic, and life-style factors as well. Nursing assessment is important as it helps know the patient better. It will help in the identification of the place they come from as well as in case of emergencies, their next of kin can be contacted. On the other hand, it helps understand the background of the patient so one can understand various aspects of a disease.
Physical Exam (Patient History, Review of Symptoms, Allergies) A physical exam refers to the procedure through which a nurse gets to understand the physical status of a patient including the identification of a person’s medical history such as allergies, symptoms and any other surgeries they may have. The nurse will need to ask a series of questions and perform several tests on the patient. A physical exam is important to help examine the physical state of a patient. It is put down in the files of the patient in order to ensure any future problems with the same symptoms can be easily recognized and treated faster. It also allows the allergies to be determined early to prevent any reactions.
Diagnosis A diagnosis can be defined as the identification of a disease, disorder, problem condition through an analysis of the patient’s history, a close examination of the symptoms, the test results should be thoroughly evaluated and the causes investigated. In order for one to identify the treatment for the disease or condition, one has to come up with a correct diagnosis. A diagnosis is of huge importance to a medical expert and must be put down in a patient’s medical health records to ensure the correct prognosis of a patient s given. It will also ensure that the symptoms are correctly ascertained, the results are evaluated and the causes are thoroughly looked into.
Procedure Preformed A procedure preformed is a term used to define the procedures that are used within medicine to help come up with a correct diagnosis for a patient’s condition or illness. This will require medical tests that can be either propaedeutic or diagnostic. These include measurement of vital signs as well as laboratory tests. The procedures performed are important as one will help ensure that the correct prognosis is given. In case one diagnoses a disease, illness, or condition, the procedure decided upon must correspond with it to ensure that all goes along smoothly. The tests performed are written down in the records so they can be monitored closely over time.
Prognosis In the medical profession, a prognosis can be defined as the identification of a cause of a disease. This requires that the nurse or medical professional comes up with proper diagnosis for the symptoms, the tests conducted among other factors that will help ensure that the patient’s exact prognosis is identified. This will in tur lead to proper treatment of the condition or disease. A prognosis sis important to help track down the symptoms that could indicate any changes within the patient’s health in future in accordance with the disease, illness or condition they may be suffering from. A prognosis can only e correct of the diagnosis the medical professional comes up with is correct.
Discharge Plan (E-prescribing) In a medical institution, when a patient is treated and kept within the facility for further study and medication of their condition or disease they need to be signed in. As soon as they are all better and ready for put patient treatment. A discharge plan is the procedures that a patient must get through before they are discharged from hospital. It also involves various stages including billing and e-prescribing. A discharge plan is important as it helps in the determination of the drugs administered on a particular patient, the time they are discharged, the kind of future treatment they may require, as well as any future complications they are likely to develop. On the other hand, the discharge plan gives the payment mode the patient will use either cash payment or insurance.
Patient Education Every nurse has an obligation to help the patient understand all issues surrounding the condition or disease. Patient education helps the patient and their family have knowledge on the condition or disease they are suffering from, the symptoms, treatment as well as prevention methods to stop its spread. The nurse is obligated to ensure that this is done in order to reduce any future cases of the disease or at least reduce symptoms and identify danger signs. Patient education must be a part of every patient’s recovery plan as it helps them identify the danger signs they should look for as well as the treatment methods that will work best for the patient in question. In addition to this, the medical health records must contain any information the patient received on the disease to make sure that ay treatment in the future can be easily administered.
Patient Demographic Patient demographic is considered the differences between the patients in terms of age, sex, race, economic status, education level, religion, death rate, birth rate, and their income. This helps understand various aspects of the disease or condition the patients may be suffering from, the capability to pay for the services they receive at a health facility as well as any chances of reoccurrence for specific diseases and conditions. Patient demographic is of huge importance as it helps in the identification of a patient’s cause of disease, illness or condition as well as nay plans that may have an influence on their recovery. Additionally, the demographics of the patient helps future treatment plans of the patient.
Insurance Information A patient’s insurance information is crucial in order to ensure that the healthcare facility can recover the payment for the services offered to the patient. Insurance information will include the name of the insurance company the patient has registered with, the type of medical insurance, the limits of the insurance, and the correspondence of the name to that offered by the patient as well as the insurance capacity. Insurance information is important as it helps the administration of the healthcare facility have in record any payment plans the patient may need to follow in future. On the other hand, the medical insurance information of a patient will help the facility make decisions on who best to partner with in future to offer better services.
Advanced directives An advanced directive in healthcare refers to the specifications that a patient draws up in a legal document to give the actions that should be carried out in case their health is compromised. This is done in order to ensure that the procedures to follow are already dictated in case they can no longer do it on their own as a result of the illness. Advanced directives help the healthcare facility during crises times such as when the patient may be in dire need of surgery as one may give information on how this should be carried out. Another example is that of the do not resuscitate rule that some people would like to apply on themselves


Himss.org. (2014). Retrieved from http://www.himss.org/library/health-information-exchange

Mather, A. (2015). linkedin.com. Retrieved from https://www.linkedin.com/pulse/what-hie-why-important-ehr-use-ashok-mathur

Hogerzei, H. V., Barnes, K. I., & Henning, R. H. (2001). Teacher’s guide to good prescribing. Retrieved from http://apps.who.int/medicinedocs/documents/s15940e/s15940e.pdf.