Electronic records have many things that great about them. They can be accessed from more than one place; different people can put things into the record at the same time, and can be saved easily. It also is very compact. You can have all the reports in one place instead of having to store things in separate places. For example, if you have an electronic medical record you can pull things up like x-ray film and CT scans. You do not have to go get the results of these tests to look at them. Manual records are a lot more of a hassle than electronic ones. Everything is either written in the record or typed and then put into the record. The record gets big and bulky. That makes it hard to stay organized and in place. You also have to search through every sheet of paper when you a looking for the specific results of something. The difference between the electronic health record, also known as the EHR, and the electronic medical record, also known as the EMR, are actually a lot of things. The EMR is an electronic replacement to the paper chart or the manual record.
It is a record of patient health information and encounters with one practice. Things such as when you go to your doctor’s office for your yearly checkup. The EHR is a record of the patients long term am aggregate health information. This is generated by all encounters with any care delivery setting. This is all the health information on one individual whether it is from the emergency room, the doctor’s office, cardiologist, or oncologist. It is all the information about a patient’s health throughout their whole life time. There are many parts to a medical record. The physical examination report is a report that states what was physically present on a person when they come into the care setting. Progress notes are notes on what happens during a patients stay at the care setting.
These can be documented by anyone that provides care for the patient during their stay. A discharge summary is a summary of what happens during the patient’s stay. Patient history is something that describes all the medical problems in the patient’s history. It goes over everything that they have been through medically throughout their life. A consultation report is something that is written to request a second opinion. It includes a brief history and maybe some specifics on why the second opinion is needed.