Question

1. You are the health information manager at a local hospital. A physician on the medical staff does not understand how to add H&P notes to a patient's EHR. He explains that he "always used to handwrite the H&P" You explain to the physician that he can no longer handwrite his H&P notes, and you give him two options of how he can add his H&P notes to the EHR. Describe these two options. A BI

Answer 1

EHR- Electronic health record

H&P- History and physical examination

EHR are made especially for doctors to improve medicine practices better and also to improve quality of care among patients they are on treatment. They do several functions, includes

a) Identify and maintain a patient record

b) Manage patient demographics

c) Manage patients problem lists

d) Manage their medication lists

e) Capture external clinical documents

f) Manage guidelines, protocols and patient-specific care plans for prioritizing their treatment plan

g) Manage their history and also

h) Manage clinical documents and notes

These are some of the functions done by EHR in healthcare organizations. These are mainly to capture accurate, relevant information about the patient treatment plan.

The method that can be used in EHR to enter data about H&P includes

1. Speech recognition: This can be done to improve the efficiency of the quality care and also used to improve the practices among patients.

2. Entry of data: Entry of data can also save the physicians time and also the data will be available all time in case of any clarifications to improve the patient care. The data being entered on this are safe and are only accessible to those who are included only in the patient care. By this method, the data can become more confidential which improves the patient satisfaction which then brings fame and fortune to the organizations.