Electronic Clinical Documentation

Topics: Citation, Electronic medical record, Footnote Pages: 9 (1122 words) Published: March 16, 2015
 Electronic Clinical Documentation Electronic Clinical Documentation, best known as computer based documentation, is an electric computer system that stores medical information of patients and patient care. It includes patient care notes and data that is shared throughout the patient hospital stay or doctor visit. Lab results, past and present medical history as well as personal data is stored in the electronic medical record. As the demand for Electronic Clinical Documentation increases, companies are finding ways to work the latest, newest innovative programs for electronic medical records. Hospitals and physicians offices are incorporating programs that give patients easy access to their own medical records. In an effort to comply with CMS or The Centers for Medicaid and Medicare, companies are searching for the best meaningful use of the programs they use for medical record keeping. Cost and efficiency. It is believed that EMR can improve cost efficiency as wellas quality of care. Cost savings are projected for potential reductions in length of stay, reduction in the demand for nurses, and reductions in redundant or inappropriate laboratory tests, radiology procedures and medications and a reduction in administrative expense for medical record

Ambra J Hopper
Gardner-Webb University
Author Note
Ambra J Hopper, Registered Nurse – Bachelors of Science Nursing Program, Boiling Springs, North Carolina

Correspondence concerning this article should be addressed to Ambra J Hopper, Registered Nurse –Bachelors of Science Nursing Program, Gardner-Webb University, 110 S. Main St, Boiling Springs, NC 28017. Email. Ahopper3@gardner-webb.edu Abstract

The world of healthcare is ever-changing. Healthcare workers are making large strides to meet the demands of the fast paced changes. The advancement in healthcare technology is one of the largest changes in the history of healthcare. Computer programs and programmers are in high demand to meet these requirements for electronic medical record or EMR. The centers for Medicaid and Medicare (CMS) are the driving force for EMR compliance by the year 2015. The Rules for Meaningful Use for EMR adoption was set forth in July 2010. “The Meaningful Use” requirement offers businesses a financial incentive to make total conversion by 2015. (What's Motivating Your EMR Conversion Plan, 2011) Electronic Clinical Documentation Electronic Clinical Documentation, best known as computer based documentation, is an electric computer system that stores medical information of patients and patient care. It includes patient care notes and data that is shared throughout the patient hospital stay or doctor visit. Lab results, past and present medical history as well as personal data is stored in the electronic medical record. As the demand for Electronic Clinical Documentation increases, companies are finding ways to work the latest, newest innovative programs for electronic medical records. Hospitals and physicians offices are incorporating programs that give patients easy access to their own medical records. In an effort to comply with CMS or The Centers for Medicaid and Medicare, companies are searching for the best meaningful use of the programs they use for medical record keeping. Cost and efficiency. It is believed that EMR can improve cost efficiency as wellas quality of care. Cost savings are projected for potential reductions in length of stay, reduction in the demand for nurses, and reductions in redundant or inappropriate laboratory tests, radiology procedures and medications and a reduction in administrative expense for medical record

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