5 Aug 2022

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The Functions of the Legal Health Record

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Health Information and Data Management 

The main function of the Electronic Health Records (EHR) in the medical office and healthcare organization is to record various patient data and medical histories like diagnoses, medications, immunization, allergies, treatment plans, and laboratory results (Ramya et al., 2018). The EHR can perform various healthcare procedures and processes like recording procedures, listing medications, and storage of healthcare information about patients. EHRs function as the digital format of the paper chart, and it makes information about the patient available. The records can also go beyond the standard clinical data and provide a better approach to patient care.

Test Results Management 

EHR can make test results manageable by facilitating improved recording, storage, and retrieval of lab test results. Laboratory results on patient data can better manage test results by alerting clinicians on lab values outside the normal ranges. The healthcare organization can manage lab results better. Additional analysis of the data can help the organization improve availability of test results. Physicians can order lab tests electronically and improve the coordination of care.

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Order Management 

EHR can prevent errors for tests and prescriptions by facilitating a detailed record of patient allergies and medications. The system facilitates the prevention of errors by checking for problems whenever there is a new medication prescribed and can create alerts to prevent potential conflicts in the medication. In case of an emergency situation and the patient is unconscious, patient records can help the clinician identify possible life-threatening allergies. The records can have prompts that pop up whenever a healthcare practitioner makes a mistake. For instance, duplicating patient records can be prevented through the system.

Decision Support 

EHR can improve treatment guidelines by facilitating better process automation and clinical decision support systems. A clinical decision support system integrated with the EHR can assist in predicting patient outcomes of a possible treatment (Ozkaynak et al., 2020). The system can generate a possible scenario by analyzing patient data and the healthcare outcomes of the patient.

Electronic Communication and Connectivity 

EHR can facilitate improved electronic communication across different healthcare platforms. It can facilitate building inter-professional relationships to improve the quality of patient care. EHR provides a way for the staff to communicate and share data in real-time. Different types of healthcare practitioners can have valuable insights and different perspectives about the patient. They can notice different symptoms and consider different possibilities. EHR facilitates the integration of different perspectives in the patient records to have a more holistic view of the patient.

Patient Support 

EHR can facilitate patient support by helping with patient education as the system creates an avenue for patient education. Such avenues ensure that providers can have an open dialogue and open line of communication either telephonically and electronically. EHR can be integrated with telemedicine to facilitate patient education. The identification of patient symptoms can be used to create personalized educational content through the use of a video library. The system can also have real-time patient feedback and requests to address patient concerns. Additional resources can be included on the platform regarding additional educational information.

Administrative Processes 

Billing and collection processes can be improved to be more accurate and more efficient. EHR can reduce the total amount providers spend on doing paperwork. Administrative tasks like processing billing data and calculating the percentage of healthcare costs are possible through the use of EHR systems (Arndt et al., 2017). Such streamlining of tasks can significantly reduce the costs associated with the healthcare system. The use of EHR is also advantageous as it minimizes denial of healthcare insurance claims and other charges related to Medicare procedures.

References 

Arndt, B. G., Beasley, J. W., Watkinson, M. D., Temte, J. L., Tuan, W. J., Sinsky, C. A., & Gilchrist, V. J. (2017). Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.  The Annals of Family Medicine 15 (5), 419-426.

Ozkaynak, M., Metcalf, N., Cohen, D. M., May, L. S., Dayan, P. S., & Mistry, R. D. (2020). Considerations for designing EHR-embedded clinical decision support systems for antimicrobial stewardship in pediatric emergency departments.  Applied Clinical Informatics 11 (04), 589-597.

Ramya, A. T., Khatheeja, S., Das, M. N., & Sanaboyina, A. (2018). Evaluation of benefits and barriers of Electronic Health Records [EHR] with their solutions: A study in multispeciality hospitals.  Annals of Health and Health Sciences 5 (2), 87-96.

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StudyBounty. (2023, September 14). The Functions of the Legal Health Record.
https://studybounty.com/the-functions-of-the-legal-health-record-essay

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