Medical Records and the Introduction of the Electronic Medical Record

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Patient medical records are a collection of patient data documenting all facts pertinent to care. Organization is standardized so that information can be accessed quickly and easily to assist medical professionals in providing optimal treatment. The purpose of the patient medical record is three-fold: to manage patient care, to create a legal record of that care, and to drive billing. While paper medical records are still the backbone of many medical facilities, they are being replaced by paperless medical records, known as electronic medical records (EMR), to facilitate ease of communication, coordination of care and effectiveness of treatment.

The Contents of Digital Medical Records

The contents of patient medical records include medical histories which should be updated every three years. They should document family medical history as provided by the patient. Social history including information about alcohol and tobacco use and other substance abuse should be included as well as milestones for pediatric patients. Related recommendations and communication with behavioral health specialists should be recorded in patient medical records. Immunizations should be listed including manufacturer and lot number and administrator of the vaccine. Finally, medical histories should include a record of chief complaints, or the reasons the patient sought medical attention. The next item in patient medical records should be the physical examination and details of the physician’s findings, particularly as related to the complaint, but not excluding any other observations. Vital signs which include pulse, breathing rate, body temperature, and blood pressure will be recorded. A diagnosis and assessment as related to the chief complaint will be documented, followed by a treatment plan or care plan. This is a map of the management of the condition including medications, lab tests, physical therapy or any other interventions. Effectiveness of medications including sensitivity and allergy will be noted. Follow-up care and test results will be recorded to ensure continuity of care. Finally, responses from specialists consulted in the care will be included.

What is an Electronic Medical Record?

As evidenced by the volume of information included in patient medical records, it is easy to imagine that hard copy versions could be difficult to manage and clumsy to access. An electronic medical record is the computerized version of the traditional chart. Electronic versions allow medical professionals to zoom in on the precise information they need to provide the best possible care to their patients. The chances of errors in medication and treatment because of poor handwriting are eliminated with medical EMR. Details of the condition are readily available in case of relapse or other family members experiencing similar symptoms. Electronic medical records are easily stored and maintained. They are impervious to loss from fire or flood. When the need arises to share information with another facility, electronic medical records accommodate instantaneous transmission.

How Do Electronic Medical Records Affect Patients?

Ease of exchange of information takes a lot of the guesswork out of emergency care and increases the effectiveness of medical intervention. It allows primary physicians to communicate rapidly and effectively with specialists and surgeons. Quick access allows doctors and nurses to detect indicators of drug sensitivity or allergy before administering medications. These factors mean that patients can receive the care they need more rapidly than ever before and with far less chance of error and duplicated or unnecessary tests. Electronic medical records are stored in multiple locations to ensure that they cannot be lost or destroyed and take up far less storage space than old fashioned charts.

What Else is an Electronic Medical Record?

EMR is a convenient method for medical professionals to provide the best care possible their patients while minimizing costs. That’s a win for both doctors and patients.