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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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Health records serve various essential purposes in the healthcare system. Here are some key purposes:
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The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
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Health Information Technology and Healthcare Information System01:30

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Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
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Methods of Documentation II: POMR01:26

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The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
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Issues And Trends In Healthcare Delivery System01:29

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The issues and trends in healthcare delivery are constantly changing. The COVID-19 pandemic is one recent issue that wreaked havoc on healthcare systems, causing a shortage of healthcare workers, high demand for medicines and supplies, and increased medical expenditure due to a lack of insurance. Other issues include rising healthcare costs and care fragmentation.
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Work-arounds slow electronic health record use.

Lea Anne Gardner1, Erin M Sparnon

  • 1Lea Anne Gardner and Erin M. Sparnon are senior patient safety analysts at the Pennsylvania Patient Safety Authority in Plymouth Meeting, PA. This article is adapted from "Spotlight on Electronic Health Record Errors: Paper or Electronic Hybrid Workflows," which appeared in a publication of the Pennsylvania Patient Safety Authority: Pennsylvania Patient Safety Advisory 2013;10(2):55-8. Contact author: Lea Anne Gardner, lgardner@ecri.org. The authors have disclosed no potential conflicts of interest, financial or otherwise.

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Area of Science:

  • Healthcare Quality
  • Patient Safety
  • Medical Error Reporting

Background:

  • The Pennsylvania Patient Safety Reporting System mandates data submission from healthcare facilities.
  • Safety Monitor informs nurses about patient safety issues and practical strategies.

Purpose of the Study:

  • To disseminate critical patient safety information to healthcare professionals.
  • To provide accessible resources for improving patient care and reducing medical errors.

Main Methods:

  • Utilizing a confidential, statewide Internet reporting system for medical error data.
  • Publishing Safety Monitor columns to share insights and best practices.

Main Results:

  • Facilitating the confidential reporting of medical errors across Pennsylvania.
  • Educating nurses on actionable strategies to enhance patient safety.

Conclusions:

  • The Pennsylvania Patient Safety Reporting System is a vital tool for improving healthcare quality.
  • Continuous education and reporting are essential for preventing medical errors and ensuring patient well-being.