Electronic Health Record Analysis

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Paper record is data collected on paper format on an individual patient. This data is standard clinical data that can include treatment, tests, and anything else pertinent to the patient. The record data is initially created at the time a patient gets admitted or is seen at the medical facility and then broken down and filed away once the patient is discharged (Davis &LaCour, 2014). Electronic health records (EHR), on the other hand, is clinical data that goes beyond the standard data collection. It is a patient’s health information - their medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results – that is created and managed by authorized providers in a digital format. In addition, EHRs allows access to evidence-based tools that providers can…show more content…
Prescriptions are sent to the pharmacy via electronically and are checked for any drug interactions and/or contraindications. In fact, this tool is called computerized physician order entry (CPOE). There is however, a disclaimer. Although CPOE can reduce medication errors and increase patient safety, it is still critical for staff, particularly pharmacy and nursing, to be alert for possible inadvertent typographical errors. A prime example of this is utilized by Harshberger et. al., (2013) in their discussion about CPOE on an oncology unit. Chemotherapy regimens are complex. With paper records, medical record number (MRN) was not included but only the patient’s name. Furthermore, the body surface area (BSA) of a patient was not always on the paper record order and not usually recalculated with each cycle. With the CPOE system, the BSA is automatically recalculated for each cycle. Again, this still doesn’t bring us in the clear because the chances of medication error is still possible being that height or weight can be entered

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