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Electronic Health Record Utilization
Electronic Health Record
- Answer the following questions:
- What is an EHR?
- What types of information are found in an EHR?
- Who manages an EHR?
- How is it used?
- Does an EHR follow the patient to other health facilities? Explain.
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Electronic Health Record Utilization
What is an EHR?
An Electronic Health Record (EHR) is a digital version of a patient’s medical history, maintained by healthcare providers to document and manage health information over time. Unlike paper records, EHRs are designed to be accessible, shareable, and interoperable across different healthcare systems, enabling real-time data updates and analysis. Introduced widely following the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, EHRs aim to improve care quality, safety, and efficiency by centralizing patient data in a structured format (HealthIT.gov, 2023).
What Types of Information are Found in an EHR?
EHRs contain a wide range of patient information, including demographic data (e.g., age, gender), medical history (e.g., diagnoses, allergies), medication lists, immunization records, laboratory and test results, vital signs, and progress notes from healthcare visits. They also include treatment plans, radiology images, and patient-generated data, such as wearable device readings. Additionally, EHRs may store billing information and care summaries, providing a holistic view of a patient’s health trajectory (Menachemi & Collum, 2020).
Who Manages an EHR?
EHRs are typically managed by healthcare organizations, such as hospitals, clinics, or physician practices, with oversight from designated health information management (HIM) professionals or IT staff. These managers ensure data accuracy, security, and compliance with regulations like the Health Insurance Portability and Accountability Act (HIPAA). Vendors like Epic or Cerner provide the software, while healthcare providers input and update patient data. In some cases, patients can access and contribute to their EHRs through patient portals, though providers retain primary management responsibility (HealthIT.gov, 2023).
How is it Used?
EHRs are used to enhance clinical decision-making, streamline workflows, and improve patient care coordination. Clinicians access EHRs to review patient histories, order tests, prescribe medications, and document encounters, reducing errors from..