EMR (Electronic Medical Record)

EMR is an electronic medical record, but can also refer generally to the system that holds EMRs and provides an interface for data entry and perhaps even test or prescription ordering. Essentially, a medical record is written documentation of a patient’s medical history and healthcare. It is also known as a health record or a medical chart. It refers to the physical folder for an individual patient as well as the information containing his or her medical history.

Medical records permanently document information relevant to the patient’s health care management. A medical record facilitates the provision of continuity of care to the patient. It also helps in planning patient care and documenting prescriptions from multiple physicians or healthcare providers. These records assist in protecting the legal interest of the patient and the healthcare provider, and help in processing of insurance claims. They make healthcare more efficient and even better, according to studies.

After each clinic visit, information about the reasons a client sought medical care, the medical history, results of diagnostic tests, and the plan of therapy is recorded. Other information may include laboratory test results, physicians’ prescriptions, referrals ordered to healthcare providers, instructions for self-care, and follow-up visits.

Physician and hospital usage of EMR systems has increased and is expected to continue to increase. Government incentives have been a factor. There will be a continual need to upgrade systems and provide consulting services to customers with existing EMR systems. Several organizations have established grades or stages to measure the health care entity’s contribution to clinical medicine.