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Medical Legal Aspects Of Medical Records - Term Paper Example

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Medical legal aspects of medical records discuss the legal process that is involved in keeping medical records. It highlights the challenges that have been posed by the documentation of medical records. …
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of Lecturer Medical Sciences 11 February Compile all the resources that you located earlier in my previous order, 498249 and formulate an annotated bibliography. The annotated bibliography should include the following Iyer, P.W., Levin, B. J. & Shea, M.A. (2006). Medical legal aspects of medical records. Arizona: Lawyers & Judges Publishing Company Medical legal aspects of medical records discuss the legal process that is involved in keeping medical records. It highlights the challenges that have been posed by the documentation of medical records.

This source relates to the critic against the use of electronic medical records as it lay claim to the fact that its unfamiliarity has made it to receive little acceptance by medical practitioners. The book dedicates some of its chapters to chiropractic care, dentistry, home care, medications and nursing homes. The book brings one to the recognition of the changes in the documentation process that was caused by changes in technology. The book clearly talked about the disadvantages of implementing electronic medical records in the documentation of medical records.

It raises the issues that are faced with the electronic medical records and also talked about the privacy, security and confidentiality issues that the electronic medical records have. It also talked about the forensic issues that the electronic system has, explaining that the failure to authenticate the data is a common problem with the electronic medical system. There are also some operational issues with the system as the authors made this very clear in the book. Electronic medical records can create problems for an attorney as they can easily spread information about controversies surrounding a particular patient.

The strengths of the book are that it does not only cover medical issues, but goes a step further in highlighting the forensic issues in the documentation of medical records. The authors took a critical look at the examination of medical records that were found as a result of forensic examination. The weakness of the book is that there is no real or central focus as the authors talked about many issues leaving the reader confused about what the real issue is. Lindh, W.Q., Pooler, M., Tamparo, C.

, & Dahl, B. M. (2009). Delmar's Comprehensive Medical Assisting: Administrative and Clinical Competencies. New York: Cengage Learning Delmar's Comprehensive Medical Assisting: Administrative and Clinical Competencies is a very good book for Medical Assisting. The book talked about several standards and guidelines for the Medical Assisting Educational programs and emphasizes the need for critical thinking in the administrative and clinical competencies. The authors talked about the coverage of the Occupational Safety and Health Administration (OSHA) and the Clinical Laboratory Improvement Amendments (CLIA) in the area of regulation.

The book also takes a critical look into the history of medicine, professional procedures and the transcription processes. The authors also discuss the importance of having practical skills in the field of medical assisting. The resource is related to the topic as it talks about the changes in the healthcare system and how medical practitioners are not really finding it easy to come to terms with these changes. The strength of the book is that it talked about some issues that are not really discussed in some other books that relates to the same field.

The weakness of the book is that it talked too much about standards and guidelines and does not really talk about how these guidelines would be observed. McDonald, C.J. (1997). “The barriers to electronic medical record systems and how to overcome them.” Journal of American Medical Information Association. 4 This journal exposes the hindrances of the implementation of the electronic medical records systems (EMRs) and it also highlights the rate at which medical institutions desire to get the EMRs systems.

It also recommends the solution to the barriers of implementing the electronic medical record systems. The journal also focused on other interface system that acts as standards such as: DICOM, IP, HL7 / ASTM, SNOMED, LOINC and other information systems developed for the medical community. The journal is relevant to the topic being discussed as it reveals the difficulties that are involved in the utilization and construction of the EMRs to work with the other technology systems in the medical institution.

The journal also explained the problems that are involved in capturing medical records in a coded form with the use of the EMRs and until these problems are solved, the system would never gain the acceptance and recognition it deserves. The strength of the journal is that it talks about the technicalities involved in the implementation and construction of the EMRs to meet the needs of the medical institution. The weaknesses of the journal are that it talked too much about problems and did not give sufficient knowledge.

Rodnick, J.E. (1990). “Should the complete medical record be computerized in family practice? An opposing view.” Journal of Family Practice. 30 The journal presents an opposing view to the implementation of the EMRs by stating that the replacement of the paper medical records with the electronic medical records would be a herculean task. Replacing the bulk of paper records used with the electronic one would not be an easy task and this was what Rodnick made readers aware in the journal. The journal is related to the opposing view on the implementation of the EMRs as it states that the implementation of the system would incur high costs.

This brings one to the realization that a lot of money would have to be spent by a medical institution that intends to replace its paper records completely with the electronic one. The journal also explains the extent at which the need to change to the electronic medical record systems are really important. The paper also emphasized the need to computerize only the needed data of the patient as this would save the time to store information that is not too relevant. The strength of the journal is that it presents a critical look at the opposing views of the implementation of the EMRs in the medical institution, while showing the importance of the information system in the process.

The weakness of the journal is that it was not really precise on whether the EMRs should be fully implemented or whether the paper medical record systems should still be used and this could confuse the reader. Wager K.A, Ornstein, S.M., & Jenkins, R.G. (1997). Perceived value of computer based patient Records among clinician users. MD: Comput This source talks about the extent at which the clinical practitioners value the computer based records. It also talked about the increase in the interests shown by the primary care physicians on the use of the EMRs.

The authors makes readers to realize that the EMRs are not widely used, but its use would be determined by the perception of the clinical users on how well they feel they can utilize the technology. It also explored the impact of the EMR system on the medical institutions and the prospects of the system after the barriers have been overcome. The resource is related to the topic in the sense that it also talked about the barriers facing the implementation of the EMRs. It also makes readers aware of the cost of incurring an EMR system.

The strength of the resource is that it tries to examine the organizational impact of the EMRs on the work life of the several users and the patients in the medical institution. No significant weakness was noticed in the material as the author made the issue clear enough with well developed points. Young, K.M. (2000). Informatics for Healthcare Professionals. Philadelphia: F.A. Davis The book talked about the influence of information technology in the area of healthcare. The rapid growth of technology has also affected the healthcare system with the introduction of the electronic medical record system.

Young makes it clear that it is the human and organizational issues that have slowed down the pace of technological development in the healthcare system. The resource is relevant to this topic as it analyzed the issues that have slowed down the growth of medical technology. The strength of the book is that it covers many issues on the development of information technology with the author making many researches on the topic in question. The weakness of the book is that it is rather complex and does not consider the readership.

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