The importance of medical record Essay

When you look at the 42 core elements established by The National Committee
on Vital and Health Statistics it reminds you of every important factor of a medical record. These elements is the foundation of a medical record from the beginning to the end. From the time a patient is admitted until they are discharged. There are a plethora of reasons why they are important but I'm going to summarize the most important elements of the 42.
The personal/unique identifier is the most important for many of reasons, most importantly who am I treating, or what stands out about this person so I won't get them confused with another patient. Next, would be the date of birth, there are 2 billion or more people on the earth and I'm quite sure there's at least one person with your name. However, how many of us has the same name and birthday. This is why this identifier is really important. Also, the Self reported health status helps with the diagnosing and possible treatment plan of a patient . Its best to know what you're dealing with then going into a situation blind sided. The admission date and discharge date is also an important factor due to prognosis. Knowing how long a patient stayed in a facility is important when getting statistics on certain diseases. Principal, primary, and qualifier diagnosis are very helpful in treating a patient and also very informative in what other symptoms may come along with diseases. Then there are the medications, which are extremely important in with treating a person it goes hand in hand with the diagnosis. Lastly, the disposition of when a patient is discharged. This helps researchers when gathering data for certain trials or gathering statistics on certain diseases, like were they alive or deceased These are the elements that stand out the most for me.
When implementing an EHR one would think how would the 42 core elements affect this process? Well a minority of the physicians and healthcare organizations have fully implemented EHRs. Recent data from the CDC/National Center for Health Statistics indicate that 25% of the office-based physicians are using at least a "basic" EHR system, and only 10% are using a fully functional EHR.[2] In the most recent Healthcare Information Management Systems Society (HIMSS) Leadership Survey,[3] 22% of the healthcare organizations reported in 2010 that they had a fully operational electronic medical record across their entire organization (up from 17% in 2009), although only 5% reported that they had not yet begun to plan for electronic medical record implementation. So with this information it all depends on the facility and money you have to implement the EHR. (www.ncbi.nlm.nih.gov/pmc/articles/PMC3049251/)
As you can see finances play a major role, this impacts how data for the CDC is retrieved, also clinical trials as well. So it really makes sense for the government to set up these incentives to get things going. Ultimately it helps with patient care and preventing clinical errors while giving this care.