Electronic Medical Records

Written by Carolyn Larson
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Electronic medical records are rapidly replacing the traditional paper method. All of the information regarding the patient is stored in digital format on a centralized server. This includes everything in the patient chart - the progress notes, test results, prescriptions, allergies, surgeries, and all patient information. There is a place to track all patient encounters. The input is quick and easy with the use of macros and templates, scanning devices, and voice recognition software.

Most software allows customization of templates to facilitate quick entry of routine examination information. Regardless of the specialty, physicians normally follow the same pattern in the process of initial patient interaction. Having a form designed with information fields to follow the same order provides an excellent format for speed and accuracy.

Features of Electronic Medical Records

Electronic medical records must comply with HIPAA standards. This is the safeguard mandated to guarantee the privacy of all patient information. It is particularly important in the electronic transfer of patient data. There must be adequate encryption of data to prohibit any third-party viewer from gaining access to the information. The correct address for all intended recipients must be verified to avoid sending the information to the wrong person.

The list of conveniences for electronic medical records is endless. It makes the records immediately available to all having permission to view the data. Physicians can have instant access to the history of a patient with just a quick query instead of thumbing through pages and pages of paperwork hunting for the right page. This is a great timesaver for anyone needing information about any aspect of the patient's record.

Timesaving Information

Many technical advances have contributed to the success and use of electronic medical records. One of these is with voice recognition software. The physician can dictate into a program designed to recognize the voice and vocabulary for a specific medical specialty. The software is configured to follow the normal routine and fill in the spaces from the dictation. This really expedites getting the information available quickly.

Medical record coding is another area that is greatly enhanced by electronic medical records. Insurance billing depends on an accurate CPT and ICD-9 code for appropriate reimbursement. These codes are entered into the computer from the physician's dictation of findings on a discharge summary. Improper coding can result in lost revenue. It is vital the information is correct and readily available for billing. Electronic insurance filing must also be under the guidelines of HIPAA for confidentiality.

More about Electronic Medical Records

Accuracy of the medical record is an absolute requirement. Standardized forms provide a pattern for all needing information from a medical record to find the information quickly. The electronic management of medical records allows queries to locate any combination of data from the record. It is easy to prepare statistical reports on various topics such as the number of gall bladder surgeries by laparoscopic procedure compared to the number by open incision. This is a great quality assurance tool.

Electronic medical records provide safekeeping of all data without the massive storage facility for row after row of charts. Safety backups of all records provide assurance that all information is preserved in a format that is always accessible with just a few strokes of the keys. For records that are not in digital format, it is easy to scan any document into the database along with all the current electronic data. It is much better to archive old records in a database than in boxes in the basement.

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