Electronic health record (EHR) is an electronic based record of a patient’s medical history. EHR is maintained by the healthcare provider and comprises the most important clinical data that includes past medical history, important signs, progress information, prescriptions, laboratory information, radiology reports, immunizations, and demographics (Green & Bowie, 2010). With EHR, the access to information for the provider and the patient is streamlined making the health care efficient. EHR has the potential of improving health care minimizing the chances of errors occurring due to inaccuracy and unclearness of the medical records, tests limits duplication, reduction in delays, and involving the patients in the decision making process.
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Paper-based records store information in files, which are kept in the registry or in the doctor’s office. Although most healthcare institutions are adopting the electronic health registers, the transition is still slow; therefore, paper based records are still widely used in American hospitals. Healthcare providers use paper based record to store radiology reports, laboratory information, medical histories, and patient’s charts. Paper based records have the following disadvantages: they require large storage space, make sharing of information difficult, limit access, restrict the patient’s contribution in the decision making process, they are prone to errors, and are expensive to maintain (Green & Bowie, 2010).
The conversion of paper based record involves the following techniques: scanning or document imaging, abstracting, and data conversion. Scanning automatically converts paper based documents into electronic content making them accessible for the healthcare provider from any location and at any time. Pre-loading or abstracting requires the manual transfer of data from the paper records to the electronic system. Data conversion is the transfer of information that is already in electronic format to a new electronic application, and entails the use of a written program. All three techniques are used simultaneously (Green & Bowie, 2010). Important information for daily health care provision is abstracted, while documents used for patient’s admissions are scanned. Records, which are seldom used, are archived in paper. The remaining paper based records can be warehoused or miniaturized.
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