Chp 1Chp 1Electronic Electronic Medical RecordsMedical Records Lesson 4:Lesson 4:Electronic Medical RecordsElectronic Medical Records

Lesson ObjectivesUpon completion of this lesson, students should be able to …

Distinguish between the use of electronic medical records and paper medical records.

Understand how to convert from paper to electronic medical records.

Discuss the steps required to properly destroy a paper medical record after it has been converted to electronic format.

Lesson ObjectivesLesson ObjectivesProvide an example of HIPAA

compliance with regard to the use of electronic medical records.

Describe the use of personal digital assistants with electronic medical records.

List the benefits of using electronic medical records.

Explain the steps to correct a mistake in the electronic medical record.

Electronic Medical Record (EMR)

An electronic means of gathering, charting, and storing information

Stored and accessed by computer

Easily accessibleon a computer

Allow physicians to easily locatepatients’ laboratory results,consultations, X-rays, andexamination findings from

other providers

Ability to access any one patient’s filefrom more than onenetworked computer

in the office

Charting patient informationis made easier

Advantage of the EMR - Accessibility!

Converting From Paper to Electronic Medical Records

Takes time scanner

Converting From Paper to Electronic Medical Records (cont)

Once transferred to the EMR, the paper record is shredded

may choose to store the paper record in a secure location rather than destroy

Addition documents may be added using a scanner

Ensuring Patient Privacy with the EMRUse password to access the medical records

logged offComputer screens must not be visible to public

Data Backup System

Mandated by HIPAAMust be used on a daily basis

not likely to lose computer data,

even if the entire computer system goes down

PDAs in the Medical Officehand-held, computer used as a personal organizer

physicians can carry from patient to patient

Benefits Gained Through Using the EMRElectronic signaturesHelps minimize medical errors

Saves timeCan be used with diagnostic equipment

Can improve communication

Avoiding Medical Errors (FYI)EMR can be used to alert health care

providers to possible medication reactions EMR software typically has a safeguard

mechanism built in that alerts the prescribing physician to any contraindicated medications a particular patient may be taking

Studies have found that medical errors are caused by indecipherable or unreadable handwriting, a problem that would be eliminated if providers made their entries electronically