2-3 Journal Assignment: Medical Health Record Templates

Medical Health Record Templates
Your Name
November 7, 2016
Your Institution of Affiliation
According to AHIMA Foundation (2016), “the PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care”.  In every medical situation, is very important because of the fact that aside from reducing the cost of treatment, it also increases its efficiency by providing past information about the patient’s medical history. However, for efficiency’s sake many healthcare providers use different templates to cater to different needs. According to Abdelhak, Grostick, & Hanken (2014), “a template is a pattern used in CPRs to capture data in a structured manner; it may contain both texts and data objects.” There are a lot of different kinds of template but most of them could vary from "simple plain text template tools to dialogue and reminder templates" CITATION Abd14 \l 1033 (Abdelhak, Grostick, & Hanken, 2014). An example of a reminder template includes a reminder (as the name implies) about an important method or procedure that the provider has to administer to the patient (e.g. checking of temperature, administering vitamins). Reminder templates are important especially for nurses’ notes, in order to make sure that medication and other medical procedures are done in a timely and correct maner. In contrast to this, there are also dialogue templates which transcribes conversations and other communications between different doctors, the attending nurses, and the hospital adminsitration regarding the diagnosis and medical procedures which are already administered CITATION Gar06 \l 1033 (Hartzband & Groopman, 2008). These days, many hospitals and healthcare providers are already utilizing Electronic Health Records (EHRs) to “streamline the clinician’s workflow” CITATION CMSnd \l 1033 (CMS.gov, n.d.). In constrast to other templates employed in Medical Records, the template employed in EHRs include as much data and interfaces possible in order to easen up and provide comprehensive and relevant inf...