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Unit 1 Assignment
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Medical Records Clerk

With the ever-growing popularity and evolution from the transition from physical to

electronic health records, many changes were made to the structure and flow of how data was

being utilized and the roles of those responsible for managing this data. The implementation of

electronic health records (EHR) also created the need for revision of job descriptions in the

medical records department. One of the jobs directly affected by the emergence of EHRs was the

job of medical records clerks. As a medical records clerk, their job is to properly collect, share,

store, and retrieve data when necessary. Before the transition into an electronic based system,

this meant that everything was written on paper and stored in the medical records filing room.

This was a long and arduous process, and because it was so time consuming, it made it difficult

for physicians to pull up patient data when desired (Campanella et al., 2016).

Due to the implementation of EHRs, many aspects and duties of the job was changed.

One of the more obvious changes was moving from paper to electronic files. This made things

easier and time efficient in many different ways. For example, prior to the implementation of

EHRs, medical records clerks had to manually fill out data and keep these files in a folder, which

was then kept in the medical records filing room (Campanella et al., 2016). In a systematic

review and analysis of the impact of electronic health records on healthcare quality, EHR use

significantly reduced documentation time, increasing time efficiency in the healthcare system

(Campanella et al., 2016). While this was beneficial to the medical records clerk, it also brought

with it the issue of a decreased need for multiple medical records clerks (HealthIT, 2018). Since

it was more time efficient to pull up the information desired on a computer, the need for a

medical records clerk to physically go looking for a patient’s file was no longer needed.
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With both the paper based and electronic based files are pros and cons that affect the

workflow of hospital-based settings. One of more common issues discussed is the problem of

misplacing or losing patient information data. With a paper-based system, it may be difficult to

find the information that was lost. However, with the electronic-based system, all the information

is stored in a “cloud”, which hospital staff and patients alike may access when desired (HealthIT,

2018). With the electronic system, there’s “instant access to anyone’s chart; no more waiting

around or lost charts” (HealthIT, 2018).

One additional way EHRs have improved health care is by increasing patient adherence

and positively affect healthcare outcomes (Cline, 2020). The implementation of EHRs made it

important for clinical nurses to also ensure that documentation is precise, correct, and completed

(Cline, 2020). Researchers argues that for this reason, there is overall improvement in patient

care and satisfaction (Cline, 2020). Another way EHRs have benefited health care is by reducing

errors and adverse events. In a systematic review to assess the impact of HER on healthcare

quality, researchers found that the use of EHRs was associated with higher guideline adherence,

reduction of medication errors, and adverse drug effects (Campanella, 2016).

In conclusion, while there are pros and cons to the implementation of EHRs, the new age

of technology will inevitably lead to universal use of EHRs in all healthcare systems. Although

there is still resistance to this change, with the proper education and funding, the transition from

paper to electronic-based systems may be smooth and seamless.

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Resources

Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W., & Specchia, M.

L. (2016). The impact of electronic health records on healthcare quality: a systematic

review and meta-analysis. European journal of public health, 26(1), 60–64.

https://doi.org/10.1093/eurpub/ckv122

Cline, L. (2020). The electronic health record and patient-centered care : Nursing Management.

Retrieved December 20, 2020, from

https://journals.lww.com/nursingmanagement/Fulltext/2020/03000/The_electronic_health_

record_and_patient_centered.2.aspx. doi: 10.1097/01.NUMA.0000654880.27546.6a

Health IT Data Summaries. (2020). Retrieved December 15, 2020, from

https://dashboard.healthit.gov/apps/health-information-technology-data-summaries.php?

state=California