Detailing Medical History On An EMR

By Belle Florentine

In a medical context, EHR means electronic health record. Sometimes the terms EPR or electronic patient record, electronic medical record or EMR and computerized patient record can be employed. That is health information and medical data about individuals or populations that's been recorded digitally. It provides a way of quickly sharing information among various authorized healthcare settings as needed. The efficiently and effectiveness of medical service providers is significantly increased.

This electronic medical history can include a comprehensive form or a summary type of the data. Information may include demographics, medical history, immunization status, medication and allergies, radiology images, laboratory test results and personal statistics for example age, gender, weight, height and billing information. It basically includes all clinical data that is relevant to a person's healthcare.

Early medical computer uses revolved around patient billing and other business functions, but there was no patient care data. The initial EHR systems started appearing within the 1960s. By 1965 it had been stated that a variety of clinical information projects and digital storage of medical documents and their retrieval were underway. Government clinical health care organizations helped develop utilization of the electronic system.

Early projects included the Computer Stored Ambulatory Record or COSTAR system that used the MUMPS programming language. MUMPS represents Massachusetts General Hospital Utility Multi-Programming System, and the language was created in 1966-67 for use within the healthcare industry. Between 1968 and 1971 COSTAR was developed at Massachusetts General Hospital in the Laboratory of Computer Science.

An EHR is typically created for each patient service from different departments such as the pharmacy, laboratory and radiology. Other records include physiological signals like electrocardiography, physician orders and nursing notes. The disparate information is integrated into the lytec system for easy access by authorized healthcare workers.

An example of the digital information system occurs at Cedars-Sinai Medical Center. Intravenous medication pumps are attached to the digital system, and it provides dosage documentation and verification. In fact, all physiologic monitoring systems show up on the network, and patient data can be seen on other hospital information systems. Doctors can even monitor a patient's EKG in their office.

The electronic medical record of patients improves the quality of care and safety of patients in a healthcare organization. Each person in a health care team is provided with reliable and relevant patient information in a timely manner. There is also the potential for spending less and making the workplace more effective by employing this digital system. There's no need for massive space for storage like there's with paper documents, and also the information is also available from remote sites.

Immediate retrieval of information that is continuously updated is a good benefit. The product can provide alerts and reminders for the medical team. The system can identify abnormal lab results or dangerous drug interactions and alert the doctors. The system could be a life saving investment for the medical community.

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