By: Ellen Sullivan
An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment. Instead of relying on paper charts, the EMR allows providers to easily store data, track it over time, identify when patients should be contacted for services and to be able to measure indicators used to monitor health. An EMR is typically used in a provider office and is basically a computerized version of the hard copy record.
There are standards for documenting in the medical record. The main concern, or the chief complaint or why the patient is a key part of the medical history. Other information includes a family medical history. Immunizations are also recorded. Documentation of the physical examination and details of the physician’s findings, particularly as related to the complaint and any other observations. Vital signs such as pulse, breathing rate, temperature, and blood pressure are recorded. A diagnosis and assessment as related to the chief complaint will be documented, followed by a treatment plan or plan of care. This plan of care addresses how to manage the condition along with the appropriate medications, lab tests, or other interventions. Discharge notes, follow-up care, referrals to specialists and test results are also documented.
There are benefits to the EMR which include:
Information is readily available to providers. It can also be shared via a secure portal to another provider when needed. Examples of how this can help includes transfer to an emergency room or if information is being to sent to another physician for follow up care.
- The chances of errors in medication and treatments reduced especially reducing errors due to poor handwriting.
- They are easily stored and not susceptible to damage from fire, flood or other calamities.
- Records can be easily reviewed with alerts set up to ensure that important information is not overlooked that may impact patient care. This is important from a patient safety perspective.
Electronic health records (EHR) are designed to contain and share information from all providers involved in the care of a patient. EHR data can be created, managed and consulted by authorized providers and staff. It also allows patients to take their health record with them and it can be shared with other health care providers, specialists, hospitals, outpatient or ancillary providers.
Most patients want to know if their records are safe and if they are kept private. In 1996, Congress passed the Health Insurance Portability and Accountability Act known as HIPAA, in order to help protect personal health information, including medical records. This law gave patients more control over their health information, set limits on the use and release of their medical records, and established a series of privacy standards for health care providers which provides penalties for those who do not follow these EMR safety and EHR security standards.
Here is a link to an article that further discusses this topic http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/