Introduction of Electronic Health Records

Electronic Health Records (EHR) is a comprehensive electronic record of patient health information which is the integration of multiple databases of health information.  The system is able to provide data such as radiology reports, laboratory data, and the immunizations, past medical history, medications, vital signs, progress notes, and patient demographics. At first, the health record in Indonesia is still known as medical records that until now were some hospitals in Indonesia are still using the same term. Medical records containing information on the evaluation of the physical condition of the patient and disease history is essential in the planning and coordination of patient care, for further evaluation and ensures the continuity of services provided.

How EHR Works

EHR documentation can be filled by clinical caregivers from doctors, nurses, dentists and others aimed at improving the efficiency, accuracy and reduce the time of recording that often takes a long time. The system is made computerized thus requiring people to record the results of documentation into a computer which can then be accessed by members of other medical. Nurses and other health workers should receive refresher and training to enter data so that no double counting is done in the next paper moved to a new EHR documentation because it is certainly a waste of time. Better documentation directly did so actions done on the patient so that anyone can access the state of a patient with certain codes. Documentation clinic records include patient assessment findings, the report notes the fact that clinics such as drug delivery, and implementation has been done. Examples of clinical documentation include records of doctors, nurses and other health personnel, a record of TTV, input and output, issues notes and records of drug administration, patient records and record moving repatriation, resume, medical records, procedures performed. Computer to entering data is an important component so that all the components included in the system can be connected directly and can be seen from any part. As with any pharmaceutical system automatically entered in EHR that includes prescription or formula drugs needed by patients. This system is very comprehensive because it covers all patient data from the name, occupation, patient data while in a hospital until administration.

The Advantages of EHR

Health documentation electronically with EHR enables the provision of health services to manage and provide care efficiently. These programs help provide health care information across the international hospital. EHR is a secure way to share information electronically which makes people make decisions about health because the information will help diagnose health problems more quickly, reducing medical errors, and provide more secure nursing services at a lower cost. EHR documentation spent far less time than with paper recording or taking notes in paper moved to the electronic system. Therefore, health workers have more time to learn about the disease or disease progression of patients who can be known with literature searches and view of the results of recent research. EHR can be a system that helps hospitals to handle a lot of patients.

Disadvantages of EHR

This system stores all the data from the first patient admitted to the hospital and is about all that is related to the patient's health. If there are data input errors, it will affect the plans or further action for the patient. In addition, if the system is malfunctioning or hacked and a virus then all existing data will be lost, this would be very detrimental to the user. At least as a nurse we could clever use system with good technology development in order to minimize the error or malfunction of the Electronic Health Records.