Electronic Medical Record

2840 Words12 Pages
INTRODUCTION Institue of Merdicine (IOM) defined Electronic health record as: “Electronic Medical Record is a system that is designed to support users through avialbilty of a complete and accurate data, practitioner reminders, clinical decision support system, links to bodies of medical knowledge and other aids.” Electronic medical record is also known as Electronic patient record; Electronic health record; Computer baseed patient record; Ambulatory medical record and Computer basee medical record. Medical record is an important part of medical practice. In the past it consisted of only a few notes about the patient, but now it contains a detailed description of patient’s information including patient’s demographics, his past history, comorbids…show more content…
The one that is ususlly used is the patient oriented medical record where all data concerning one patient is put together. It can have several formats for example chronologically arranging all the patient’s record or problem oriented medical record where all the active and resolved problems of the patient are kept at the front. Thus, the data can be arranged in different ways depending on the preference of the health institution. SIZE OF ELECTRONIC MEDICAL RECORD Present Electronic medical record system (EMRS) contains a large amount of information about a patient and a detailed information about the health care providers directly or indirectly involved in providing care. The information regarding patient includes patient’s demographics; current health status of the patient; his past medical history; allergy and drug history; information about insurance and billing records for the medical procedures done in that institution. In relational database terms, the size of this huge data is stored in thye form of hundereds of relational tables, each having tens of different fields and the number of record is in the range of…show more content…
Firstly, the clinical notes that were made in the past were written by the physicians and thus were sometimes not legible. With this new system notes are made on computer and are legible so there are decrease chances of error. Secondly, patient’s lab tests, results and reports can be ordered on computer and physicians can be immediately warned for abnormal results. The blood bank; pathology and microbiology labs can also be contacted easily via computer. Thirdly, reminders can be set for the paramedical staff for administering vaccines and providing patients with medicines. Fourthly, the data can also be used for clinical research and for management of prevailing chronic diseases like diabetes and hypertension in public. Fifthly, this system also introduced a modern pharmacy system that provides information regarding drug interactions, allergy alerts and drug monographs that can be use by the physicians while prescribing the drugs. Sixthly, the data can also be used for program monitoring that includes reporting outcomes, budgets and supplies. Seventhly, nursing staff can use this system to store and collect nursing documentation; care planning and administrative information. Apart from that this system can also be used by Hospital information system to manage hospital census and billing which are mainly linked to departmental systems. Also, systems like picture
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