EMR

Electronic Medical Record

Electronic Medical Record

Introduction

An electronic medical record is a secured electronic file of patient history, medical notes from the transcript, the billing information, and all other information necessary for a complete patient profile (Kenneth 2001). It is true that the electronic medical record is indicative of an information age fast-paced in which larger amounts of information require more effective infrastructure for the database, but there are many more advantages to the medical service provider and the consumer (Dick, 2000).

Discussion

Implementation of EMRs

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 .

Health care has historically been a very private and personal experience, typically occurring behind closed doors between an individual patient and health provider. However, implementation of EMRs may be changing that experience. In a web site for EMR software reviews, summarizes the features of many different EMRs for group and individual health practice settings. In these reviews, a common feature suggested is that documentation will now be more legible and accessible to one's own health colleagues (e.g., psychiatrists, nurses, and others), who may now be providing shared or integrated care (McDade, & McKechnie, 2004)

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.

In a significant administrative and clinical transformation, approximately seven years ago, Group Health Cooperative (Group Health) undertook the process of converting their entire medical records system to an EMR. As a result, it was difficult to coordinate care (paper charts were sometimes incomplete, not present at each appointment, and were often difficult to read) and there was inefficiency both in terms of infrastructure (space and people needed to maintain paper chart systems) and quality of care (tracking prescriptions, reviewing which tests had been ordered, etc.).

Clinical Documentation Templates

The first step in our department implementation process was determining 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 ...