Introduction to Data Entry and Electronic Health Record.pdf

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1. Introduction to Data Entry
and Electronic Health
Record
-Dr. Kris Agarwal
Senior Resident, DoHA

2. DEFINITION OF MEDICAL RECORD
Aclinical,scientific,administrativeandlegaldocumentrelatingtopatientcareinwhichsufficient
dataarewritteninsequenceofeventstojustifythediagnosisandwarrantthetreatmentandend
results.
-Mc Gibony(1969)
Thecollectionofinformationconcerningapatientandhisorherhealthcarethatiscreatedand
maintainedintheregularcourseinaccordancewithpolicies,madebyapersonwhohas
knowledgeoftheacts,events,opinionsordiagnosesrelatingtothepatient,andmadeator
aroundthetimeindicatedinthedocumentation.
-World Health Organization

3. •A medical records document serves as :
Clinicaldocument-listingtheclinicalhistory,physicalexamination,investigations,
nursingrecords,etc.
Scientificdocument-isusedtostudythepatient’sconditionandprogress
throughscientificallypractisedmedicineandforresearch.
Administrative document -it helps administrative control, planning of services,
budgeting, improving quality of care and hospital statistics.
Legal document -admissible under Indian Evidence Act in law courts in defending
malpractice suits (unethical practice), in law torts (common law jurisdiction) is a civil
wrong that causes a claimant to suffer loss or harm, resulting in legal liability for the
person who commits the tortious act.

4. CHARACTERISTICS OF GOOD
MEDICAL RECORDS
•Medical Records must be :
I.Complete-sufficient data to identify the patient, justify diagnosis,
treatment, follow-up and outcome.
II.Adequate-with all necessary forms, all clinical information.
III.Accurate-capable of quantitative analysis.

5. EfficientandaccuratedataentryisthefoundationofarobustElectronicHealthRecord(EHR)
system,
•Ensuringpatientcareand
•Streamliningtherecord-keepingforhealthcareproviders.

6. Importance of Accurate Data Entry in Healthcare
1Patient Safety
Precise data entry
helps prevent
medical errors and
ensures patient
information is
accurately recorded
for safe, effective
treatment.
2
Care Continuity
Consistent data
entry across
providers enables
seamless patient
care and history-
keeping for better-
informed clinical
decisions.
3Regulatory Compliance
Adherence to data entry
standards is crucial for
meeting legal and industry
requirements for medical
record-keeping.

7. EMRs enable better coordination of
care, reduce medical errors, and
provide real-time access to patient
histories and treatment plans.
4Improved Patient Outcomes
5Increased Efficiency
EMRs automate administrative
tasks, eliminate paper-based
records, and improve workflow,
allowing staff to focus on patient
care.
6Enhanced Data Management
EMRs centralize patient data, enabling in-depth analytics to identify trends, monitor population
health, and support evidence-based decision making.

8. ELECTRONIC HEALTH RECORD & STORAGE
•AnEHRisthesystematizedcollectionofpatientandpopulationelectronically-
storedhealthinformationinadigitalformat.
•ElectronicHealthRecordisstoreddigitallyinasecurecomputerdatabase
withinanorganizationorhealthcaresystem.
•Thissystemallowselectronicstorage,retrievalandmodificationofmedical
recordsandisanalternativetotraditional,papermedicalrecords.

9. Disadvantages of Paper Records
•Paperchartsareneitherinteractivenorintuitivelydesigned.
•Printedremindersandcautionscanbeeasilyoverlooked.
•Physiciansarenotoriousforillegiblehandwriting-aslessas65%ofthewritten
medicalchartscanbefullyread.
•Nodatasharing-writtenrecordsremainintheprovidersoffice.
•Takealotofspace.
•Disorganizationordisasterinofficecanresultininformationloss.

10. Overview of Electronic Health Record (EHR) Systems
Definition
EHR systems are digital platforms that centralize and manage patients' comprehensive
medical histories, including clinical data, diagnostics, and treatment information.
Key Components Benefits
EHRs improve workflow
efficiency, data accessibility, and
care coordination for healthcare
providers and patients.
•Patient demographics
•Clinical notes and orders
•Medication management
•Lab results and imaging

11. Key Features and Benefits of EHR
Improved Accessibility
EHRs allow authorized users
to securely access patient
records anytime, anywhere,
enhancing collaboration and
decision-making.
Enhanced Efficiency
Automated workflows,
template-driven
documentation, and point-of-
care data entry streamline
clinical operations.
Increased Accuracy
EHRs minimize errors
through features like drop-
down menus, auto-fill, and
data validation checks.
Better Outcomes
EHRs support evidence-
based care, preventive
health initiatives, and
population health
management for improved
patient outcomes.

13. 1.Clinical decision support system (CDSS)
2.Computerized physician order entry (CPOE) systems
3.Health informationexchange(HIE)
Components of Electronic Health Records

14. 1. Clinical Decision Support System (CDSS)
CDS system is a software that assists the provider in making decisions with regard
to patient care.
CDSS provides physicians and nurses with
real-time diagnostic and treatment
recommendations.

15. •Managing clinical complexities
•Monitoring medication errors
•Avoiding duplicate and unnecessary tests
•Supporting clinical diagnosis & Treatment plan processes
•Promoting use of best practices & condition specific guidelines & Population
based management.
•Providing latest information about a drug, cross-referencing a patient allergy to
a medication, and alerts for drug interactions and other potentialpatientissues.
Functions of CDSS

16. CPOE is a software that allow physicians to
enter orders directly into the computer
rather than doing so on paper.
Example:
•Drugs
•Laboratory tests
•Radiology
•Physical therapy
2. Computerized Physician Order Entry (CPOE)

17. •Eliminates potentially dangerous medical errors caused by poor penmanship of
physicians.
•Eliminates errors caused by unclear telephone orders.
•It also makes the ordering process more efficient because nursing and
pharmacy staffs do not need to seek clarification or to solicit missing
information from illegible or incomplete orders.
•Enhancespatientsafety.
Benefits of CPOE

18. HIE is the process of sharing patient's
electronic health information between
different organizations and can create many
efficiencies in the delivery of health care.
Once health data are available electronically
to providers, EHRs facilitate the sharing of
patient informationthroughHIE.
3. Health Information Exchange (HIE)

19. Benefits of HIE
•Allows for the secure and potentially real-time sharing of patient information.
•HIE can reduce costly redundant tests.
•HIE facilitates the exchange of this information via EHRs, which can result in
much more cost-effective and higher-quality care.

20. 1.Picture archiving and communications system
2.Bar Coding
3.Radio frequency identification
4.Automated dispensing medicines
5.Electronic medication administration records
Technologies Involved in Electronic Health Records

21. 1. Picture archiving and communications system
This technology captures and integrates diagnostic and radiological images from various
devices, stores them, and disseminates them to a medical record, a clinical data
repository, or other points of care.
e.g., x-ray, MRI, computedtomographyscan.
2. Bar coding
An optical scanner is used to electronically capture information encoded on a product.
Initially, it was used for medication.
•It consist of bar code readers, a portable computer with wireless connection.
•The nurse can verify patients aswellasdrugs.

22. 3. Radiofrequency identification
This technology tracks patients throughout the hospital, and links lab and medication tracking through a
wireless communications system.
It is neither mature nor widely available, but may be an alternativetobarcoding.
4. Automated dispensing medicines
These are computerized drug storage devices which allow medications to be stored and dispensed near
the point of care while controlling and tracking the drugdistribution.
5. Electronic medication administration records
•The EMAR alerts the nurse about the next dose or cautions about the medications.
•Nurses take the cart near to the patient, scan the medication and the patientwristband.

23. Challenges in Transitioning to EHR
Technical Barriers
Integrating EHRs with existing IT systems, ensuring data
migration, and providing end-user training can be complex.
Change Management
Overcoming staff resistance to new workflows and processes
requires effective communication andsupport.
Financial Investments
Implementing and maintaining EHR systems can be costly,
necessitating careful budgeting and resource allocation.

25. Best Practices for Efficient Data
Entry
Standardize
Adhere to consistent
data entry protocols
and terminology for
better interoperability.
Minimize Clicks
Optimize EHR workflows
to reduce the number of
steps required for data
input.
Automate
Leverage EHR features
like templates, macros,
and voice recognition to
streamline data entry.
Validate
Implement data
validation checks to catch
and correct errors before
they are saved.

26. Ensuring Data Security and Compliance
Data Encryption
EHRs must use robust
encryption techniques to
protect sensitive patient
information during storage
and transmission.
Access Controls
Granular user permissions
and audit trails are essential
for restricting and
monitoring access to EHR
data.
Regulatory ComplianceHealthcare organizations must adhere to
industry standards and regulations, such as
HIPAA, to ensure data privacy and security.

27. Integrating EHR with Other
Healthcare Technologies
1 Interoperability
EHRs must seamlessly connect with other
systems, such as practice management,
telehealth, and lab information, to enable
comprehensive data exchange.
2 Remote Monitoring
Integrating EHRs with wearable devices and
remote patient monitoring tools can provide
real-time health data for better-informed care
decisions.
3 Artificial Intelligence
AI-powered EHR features, like predictive
analytics and clinical decision support, can
enhance workflow efficiency and patient
outcomes.

28. Training and Support for Data Entry Personnel
Comprehensive Training
Offering in-depth training on EHR
functionality, data entry best practices,
and clinical documentation standards
is essential for staff proficiency.
Ongoing Support
Providing dedicated IT support, user
manuals, and continuing education
opportunities helps ensure data entry
personnel stay up-to-date and
confident in their skills.
ProductivityMonitoring
Regularly reviewing data entry metrics
and workflows can identify areas for
improvement and inform targeted
training and support initiatives.
Continuous Feedback
Encouraging open communication and
soliciting feedback from data entry
staff helps organizations enhance the
EHR user experience.

29. Future Trends and Innovations in EHR
Voice-Driven EHRs
Advancements in natural language
processing and voice recognition will
streamline data entry and clinical
documentation.
Predictive Analytics
AI-powered EHR systems will
leverage data to predict patient
risks, recommend treatments, and
optimize care delivery.
Patient Engagement
EHRs will become more patient-
centric, empowering individuals
to access their health data and
actively participate in their care.
Telehealth Integration
Seamless integration of EHRs
with remote patient monitoring
and virtual care platforms will
enhance access to healthcare.

30. THANK YOU