Electronic Health Records - an overview of the issues that surround the implementation of paperless hospitals and are able to support shared care between providers in different services and locations. This unit is all about capturing information from the clinical encounter into an electronic health record system, so that data can be viewed for patient care by multiple providers, as well as abstracted for clinical analysis and research, and for business and financial management. This unit forms an essential base upon which many of the following units aim to build and expand. HI203-01 should be completed prior to enrolment in this course.

Learning Objectives - on completion of this study module, including all the associated eLinks, the student should be able to demonstrate Knowledge and Understanding of the following topics and issues:

  1. Medical Records and the types and categories of information that may be recorded
  2. Approaches to organisation of the contents of the medical record, both static and dynamic
  3. The need for and potential benefits to be expected from keeping medical records in an electronic form
  4. The principal shortcomings of records held on paper with particular reference to legibility, data abstraction, record fragmentation and inability to apply computer-based intelligence
  5. Essentials of electronic record keeping systems – EHR, EMR
  6. Obstacles to the adoption of electronic records systems, including costs, privacy and security issues, and patient and professional ‘comfort’ with such systems
  7. Manipulating information in electronic formats, distinguishing especially between ‘free text’, image-based material, and structured, classified and/or coded data
  8. Methods for data entry, including bar codes
  9. Organising medical records into ‘meaningful’ collections relating to a specific event, encounter, episode of care and/or illness/condition
  10. An outline of communication of information, and medical messaging.