9.14: Methods of Documentation VII: EMR
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings, facilitating the delivery of patient care within that organization.
Electronic Health Records (EHRs) encompass a broader scope of patient health information, extending beyond the confines of a single healthcare organization or encounter. They integrate data from multiple sources and care settings, including medical histories from various providers, lab results from different laboratories, imaging reports, pharmacy records, insurance claims data, and patient-generated health information. EHRs provide a longitudinal view of a patient's health history, facilitating continuity of care, care coordination across different providers and settings, and comprehensive clinical decision-making.
Characteristics of EMR or EHRs:
- • They consist of structured collections of patients' digital medical records originating from electronic formats or converted from paper records.
- • The information is digitally stored in electronic records. It can be easily distributed to healthcare providers in standardized formats, enabling efficient comparison and assessment of patient progress.
- • Healthcare facilities use standardized assessment tools like the minimal data set to systematically organize and document patient information.
- • The minimal data set typically includes nursing care components (e.g., diagnoses, interventions), patient demographic information (e.g., gender, date of birth), and service components (e.g., admission, discharge dates).
Critical Benefits of EMRs to Nurses:
- • EMRs offer several benefits to nurses, including the ability to compare ongoing clinical data with baseline data, maintain detailed patient logs, and quickly access patient records.
- • They facilitate legible, accurate, up-to-date, and complete documentation about patients, improving efficiency and quality of care delivery.
