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Computerized medical records: 10 advantages

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Computerized medical records: 10 advantages

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EMR, EHR, computerized medical records
1. There is 20-50% waste in any healthcare system. EHRs (electronic health records) help to remove some of that waste.
2. Pen and paper medical records are plagued by illegible handwriting along with non-standardized and dangerous abbreviations, which can lead to medical errors. Electronic records are legible and are programmed to use only approved terminology and abbreviations.
3. Electronic medical records may be supplemented with resources, such as information about medications, which is useful when prescribing drugs. Systems that include data from laboratory systems can incorporate clinical prompts, for example, which may warn against prescribing a specific medication in the presence of declining kidney or liver function.
4. Use of bar coding technology reduces medication errors.
5. Programs can be designed to include unit-specific and agency-wide standards of care and practice. The effect of these programs is to remind the provider of the essential elements that must be documented, through the use of clinical flags.
6. Access to a medical record may be electronically limited. For example, a nursing assistant may be permitted to only enter vital signs but not review orders, laboratory results, or write nursing notes. A paper medical record may be viewed by anyone.
7. Each entry in the electronic medical record carries a time and date stamp, as well as the identity of the user. This makes it easier to reconstruct events after a patient injury occurs.
8. Tampering with the medical record is much more difficult to do with an electronic system. Software typically permits the healthcare professional to correct errors in typing and phrasing immediately after the error is made. Software programs contain a feature that makes the entry unalterable after a certain time or event.
9. With sufficient safeguards in place, an electronic record is more reliable and less likely to be lost.
10. Failure to authenticate a medical record may permit alterations of data after the entry should have become permanent. Authentication finishes a record entry, making it permanent. For example, a nurse who fails to authenticate nursing notes until the end of an eight-hour shift may make changes after an event has occurred.

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