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Landstuhl Regional Medical Center
Servicemembers used to hand carry their medical records from appointment to appointment, then back to the records room. No longer the case, as electronic records already have become the standard.
The Army has had a no hand carry policy for several years and the Air Force recently has adopted the policy.
The electronic record will make records safer by limiting access to them, make them more accurate and legible by eliminating the need for handwritten doctor notes. When fully implemented throughout the Department of Defense, information will be stored in multiple locations and chances of lost information will be virtually nonexistent.
Hard copy records remain in the records room, predominately. When an outpatient appointment has been scheduled, the records still will remain in the room unless they are requested by the patient’s physician. The only time the records for an outpatient would be needed is if the doctor needs to review the patient’s past history, as the electronic record goes back only one year. All inpatient appointments use the actual record because the Composite Health Care System (electronic record), now called AHLTA, is not yet set up for inpatient appointments.
“It takes us twice as long to enter the data when using the electronic record, but the advantages to the system are overwhelming,” said Dr. (Lt. Col.) Warren Dorlac, chief of the LRMC Trauma Division. “The information is available immediately and can be accessed at any medical treatment facility that uses AHLTA. It also isn’t dependent on the physician’s handwriting.”
Time consuming data entry also is being eliminated by using a device called Dragon Speak – a program whereby a doctor’s speech automatically will be transcribed onto the electronic record.
As is the case with everything, the system is not yet foolproof. Records still have the potential to be misplaced, but with electronic data, all is not lost.
