EMR SYSTEM

Plans to develop a new emr system in a medium size family practice

Plans to develop a new EMR system in a medium size family practice

Introduction

An electronic medical record (EMR) is a patient's medical information in an electronic format. This medical information is accessible via computers on a network to provide health care and health services. EMRs contain information concerning the past, present or future physical and mental health of a patient reports of medical tests, medical images, financial and demographic information. In addition, order medical tests, medications, treatments, and clinical guidelines are available in the EMR. The data contained in sound can be captured and transmitted securely and in real time by users at the point of care (Colwell, 2005).

Health treatment in itself requires an integration of patient and provider information. From patients' perspectives, they may wish to share emotional experiences and how these impact their lives. From providers' perspectives, they called upon to develop clear, conceptual treatment plans from diagnosis to interventions to functional impact, to assist our patients. Given this field's unique demands for obtaining, analyzing, and integrating these different types of information systematically, the health field is ideally suited for the use of the modern technology found in an electronic medical record (EMR).

EMRs

EMRs were developed to provide a more efficient and accurate method of clinical documentation. An EMR is essentially a computer database that contains a variety of information relating to patient care. It is more than simply an electronic version of a paper record (Luo, 2006). However, as is true for other medical specialties. Although health providers can document the diagnosis, treatment plan, and encounter notes into the EMR in the same way physical health providers do, detailed background to the presenting problem, or develop and family historical information germane to health may not so readily fit, and thus customized templates are also useful.

Discussion

As a project manager, the first step in our department implementation process is to determine how to setup the structure of clinical documentation. The documentation template in an EMR would be the foundation and framework for all charting or documentation to be done by every discipline. In reviewing a number of existing EMRs designed, the documentation template appears to be a common and fairly key feature among all of the health EMRs reviewed (Luo, 2006).

In simple terms, in health documentation there are two major types of notes: the initial evaluation ...