Question

A Day in the Life of the Electronic Health Record:

You are 65-year-old woman going to a large MultiCare health setting for an annual physical examination. When your appointment was made with the primary care physician’s nurse practitioner (NP), she noted that your physician will want fasting laboratory work, mammogram, and a dermatology screening. You explain that you also need a follow-up visits at the sleep clinic. All appointments are scheduled for 1 day. When you arrive, you go first to the laboratory for the blood draw and urinalysis. Then you have time for breakfast in the clinic’s café before you see your primary care physician.

When you are in the examination room with the NP, she is able to pull the morning’s laboratory results on her computer. She turns the computer toward you and is able to show you today’s results on a spreadsheet with the last 2 years’ results for comparison. Discussions follows. Your next stop is for a mammogram. The results of that test will be mailed to you. You hasten on to the sleep center, where the provider discusses your continues positive airway pressure (CPAP) registry that shows on his computer how many hours a night you have successfully used the breathing apparatus. He comments that your primary care physician indicates in today’s chart notes that you are using a new mask and nasal pillow system that you purchased on the Internet. The final day’s visit is to dermatology, where you receive a full body screening for any changes in your freckles, moles and aging spots. A suspicious mole on your lower check causes the dermatologist concern. She removes the mole and takes a biopsy and will notify you of the results. The dermatologist says, “I’ve looked at your chat; you’ve had a long day! Are you ready to go home now?”

Refer to the vignette "A Day in the Life of the Medical Record." As a client, how did the availability of the medical record facilitate the care received? As a health-care provider, what are the advantages of having up-to-the-minute information on a client? Discuss the legal implications of a medical record used in this manner.

Answer 1

In traditional methods the people would have to first take an appointment with the physician and then meet them , take different dates for different tests without knowing if you will get the chance of doing the test with so many patients in queue waiting for their turns, it was very hectic with just the information that we used to put in the file on writing.

But today with new technologies had made not only the work of the client easy but also the health care memebers are relieved with so many hectic works. Also the patient's information are saved and kept safe within the system without letting the unnecessary revelation of data.

As a client, the availability of the medical record has facilitated in the care received alot. I was able to complete all my tests in one go, I did not had to run from one lab to another without having the clue of which one is next, I did not had to wait long to get my reports, and most important part was that before I could go and meet my physician my reports were shown to me which was ready within no time and I was also allowed to see the changes that has happened to me and my body since 2 years which made me become a part of my health care team.

As a health care provider, the advantages of having up to the minute information on a client are:

- we can make our life easy by not having to go through all the old files and records and check her status according to it

- it saves our energy and time

- it makes us confident to talk to the patient and his family memebers about his condition and status.

- it helps us to see the progress of the condition of the patient

- it gives us knowledge on the patient's past and present reports which will help us to tally between them.

- it will help us to know about the procedures, tests, medications for the client and will help us to see the side effects and work accordingly.

The legal implications of the medical record used in this manners are:

- the patient's infinformation are confidential

- the patient will have full authority of the knowledge of his or her condition

- the health care team will always have a record proof for themselvea