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Medical Records

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Kimberly Young

American Intercontinental University

Unit 3 Individual Project

HLTH430-1102A-01 Healthcare Information Systems

May 15, 2011

Electronic Medical Records

An application that is composed of clinical data and supports a patient's medical record. This application will support the patient across all aspects of their healthcare and is a legal record of what has happened to a patient throughout their medical history.

An electronic medical record or EMR is a digital record that is kept by a doctor, insurance company, or any facility that sees patients (What is an EMR?, 2011). The EMR was born of the Health Information Technology and are intended to keep track of a patient's health and medical history in its entirety. This record is kept in an electronic computerized format. It is thought that by keeping patient records in this manner it will make it more efficient and safer for a patient to navigate through a healthcare system.

An EMR is usually comprised of two different kinds of records. There is a patient's older record dated pre-2000 and these records are scanned and then stored in a pdf form. These records will include doctor notes, test results, and x-rays as well as other medical information. Records that are more recent will be electronically native. This means that they were generated electronically to begin with and were never stored in any other fashion (Glandon, Smaltz, & Slovensky, 2008).

A complete EMR system has been defined by the Federal Government as a system that contains four basic functions. These four functions are:

1. Computerized orders for prescriptions

2. Computerized orders for tests

3. Reporting or test results

4. Physician notes

These functions are not federally regulated and a patient's doctor may keep even more types of records than what they have defined.

The Centers for Disease Control and Prevention have stated that according to data from 2008 there were 43.9 percent of physicians that are using all or partial EMR systems (Electronic Medical Record Use by Office-based Physicians, 2009). The basic systems that physicians are using include functions like:

1. Patient Demographic

2. Patient problems

3. Clinical notes

4. Prescription orders

5. Labs results

6. X-ray results

The fully functioning systems that some physicians are using include the above mentioned functions as well as medical history, follow up orders, warning of drug allergies and interactions, reminders for guideline based interventions as well as many others.

There are many benefits to using an EMR system. Some of the benefits include:

1. Important information is readily available to doctors all across the world such as blood type, prescribed drugs and medical conditions.

2. Safety - An EMR is much safer for the patients because in the past a doctor or health care organization had to get information from the patient and now it is readily available without having to fill out mountains of paperwork that can easily not have all of the important information that is needed.

3. Save time - With quick access to medical information lifesaving treatments can be administered without having to wait for information.

Other advantages of an EMR are that information is shared over the internet and doctors have the ability to update the data immediately and also do research. The system has helped doctors to see and diagnosis a patient in correct



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