Question one
Charting is a critical exercise that details the information exchanged between a patient and a medical expert. With the advancements in technology, there have emerged revolutionized charting processes that are slowly replacing paper charting. Data in a medical chart helps other professionals understand what was done, the next course of action, and what is planned for patient care ( Oberg & Villemaire, 2017 ). One type of charting in electronic records is electronic prescribing (E-prescribing). E-prescribing replaces the paperwork by allowing doctors to have direct communications with pharmacists ( Sim et al., 2019 ). Instead of a physician writing prescription information on a piece of paper, they can input the detail on an electronic form and send it directly to the pharmacist. Those working in the pharmacy will pull up the information on their computer through the database. Both paper charting for prescription and e-prescription capture the same information. For example, they may indicate a patient's personal information, sickness, diagnosis, test results, and prescription.
E-prescribing has many benefits compared to the paper charting for inputting prescription information. First, e-prescribing will help save emergency care providers time when a patient visits a hospital. Hospital time is critical for overall patient care outcomes, and as such, e-prescribing charting helps preserve it. Second, e-prescribing is more secure than paper charting for recording prescription information. A patient may misplace the paper prescription document forcing their doctor to write another one. The last benefit of e-prescribing is the ease of access. Paper records are tedious to access and share, and sometimes they may not be found. With e-prescribing, information can be retrieved even at a later date ( Sim et al., 2019 ). However, e-prescribing is initially costlier compared to paper charting for a prescription. For a facility to have e-prescribing, the management must purchase, install, train, and fully utilize it. All these processes are capital intensive, which makes this form of charting more expensive than paper charting.
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References
Oberg, D., & Villemaire, L. (2017). Grammar and Writing Skills for the Health Professional (3rd ed.). Boston, MA: Cengage Learning.
Sim, N. K., Walter, T., Pickin, S., Stanger, S., Tanqueray, E., Sperrin, J., ... & Isaac, T. (2019). 57 Exploring the functions of an E-prescribing system to reduce prescribing errors and improve inpatient medication record keeping
Question Two
There are several types of charting that can be used to capture a patient’s information during an engagement with a medical practitioner. The two most common are the problem-oriented medical record (POMR) and source-oriented medical record (SOMR), with the latter being the best for this discussion. SOMR is a traditional format for conducting charting tasks at the source. SOMR charts are divided into particular sections that capture different client's information. The person inputting the data must make sure each type of information is entered in the correct part of the chart. Some of the divisions include progress notes, nursing assisting notes, laboratory notes, diagnostic notes, and history, and practical information ( Oberg & Villemaire, 2017 ). In this type of charting, there is no systematic cross-referencing of information between sections. It is noteworthy to note that progress notes must be recorded in narrative design, thus necessitating that one read the complete information before developing a conclusion on the patient's condition. Reverse chronological order is used to document information in a SOMR chart.
I think that SOMR is the ideal type of charting because it allows a doctor to see the whole picture before embarking on an analysis. The SOMR comprises a client's medical history from the beginning to the end, which forms the basis for predictability and accurate evaluation. SOMR also provides an opportunity for extensive consultations among the medical members because each one has their charting record. From the discussions, the team can develop a viable course of action on a patient's condition. However, because SOMR is time-intensive, it cannot be used in all areas of medicine ( Heller, 2016 ). For instance, in an emergency scenario, POMR can work better than SOMR. Emergencies require medical teams to rapidly retrieve patient's information, analyze, and comprehend within record time so that they can make quick decisions. Nevertheless, the two can be used to reinforce each other in different scenarios.
References
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Heller, M. (2016). Clinical Medical Assisting: A Professional, Field Smart Approach to the Workplace . Cengage Learning.
Oberg, D., & Villemaire, L. (2017). Grammar and Writing Skills for the Health Professional (3rd ed.). Boston, MA: Cengage Learning.
