Electronic Health Record (EHR) Electronic Health 17-AAG mechanism Record (EHR) captures, transmits, receives, stores, retrieves, links, and manipulates multimedia in providing health-related services [20]. EHR facilitates the communication of patient information among different professionals [21]. These support tools potentially reduce memory strains of clinicians and improve efficiency and effectiveness in healthcare quality improvement [22]. The accessible patient information has tremendous potential to reduce errors, and support functions. As it is depicted in Table 1 below, these roles or functions include: Table 1 Expected electronic health record tasks Memory aid: Reduces the information need to rely on mental memory to complete a task. Computational aid: Reduces the need to mentally compare or analyze information.
Decision Support aid: Enhance and integrate information from sources to make decisions. Collaboration aid which: Enhances information communication among providers and patients. EHR holds great promise and success in improving safety, efficiency, timeliness and quality of healthcare with special emphasis is given to interface support tools and secured confidentiality [23]. The quality of records generated and maintained is a reflection of the quality of the healthcare provided. Record management as well as accountability is therefore the cornerstone of good clinical practices. This alerts healthcare providers to prepare and make explicit rationale for decisions making and justify service in the context of evidence-based practices [24].
Computerized documentation may improve or worsen information availability. It could lead to less reliable and less trustworthy documentation than the former paper notes. All responsible groups are expressing their worry about the risk of careless copying and pasting of texts which is less trusted. Moreover, clinicians experience pressure from their stakeholders to document the services provided related to reimbursement. However, there were problems related to disorganized processes of simple insertion laboratory results, vitals, medication lists, and problem lists that could be misleading [25]. Research findings on record and documentation of patient data In the United States medical error results in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries per year.
Rate of error often increases when inexperienced clinicians introduce new procedures. It had more severe impact associated to extremes of age, complex care, and prolonged hospital stay [26]. Sixty five (3.5%) Batimastat of 1,934 prescribed agents, Swiss University Hospitals, have committed medical errors. Forty three percent of patient charts showed at least one error. Prescribing errors were found 39 times (37%), transcription errors 56 times (53%), and administration documentation errors 10 times (10%).