RISK MANAGEMENT

OFFICE SYSTEM IMPROVEMENTS

ELECTRONIC MEDICAL RECORDS (EMR): Defining the Important Elements

• Lost or misfiled records or record components
• Illegible handwritten entries
• Unrecorded or inaccurately recorded observations or interventions

1. The primary function of an EMR is Storage. In the system, patient notes, and various documents, such as, informed consent/refusal and outside correspondence must be secure, password protected, and have the capability to audit users of the system. Each patient visit or interaction, and other related documents or correspondence, must be stored and accessed by the system in a manner similar to storage in a medical chart rack for paper based medical files.



2. Information must be organized to include patient demographics, medications, appointment recall, translation of telephone messages into documented notes and HIPAA compliance. The system must organize basic patient medical information into useful groupings for follow up and decision-making.



3. Present medical records by viewing and printing a hardcopy by each authorized user, which will assure a standardized structured medical chart, flow sheet, medication lists and report capabilities. This standardization will permit users to quickly find important medical information. The EMR should also present information via reports and search functions in ways that are not possible with a paper chart.



4. A Virtual Data Base will securely store data for easy viewing recall and eliminate lost charts. This database minimizes lost or misplaced paper charts. All medical information should be stored in the main server, allowing authorized users to access copies of the particular chart from their workstations no matter where they are located.



5. The EMR should allow Input of Patient Data into the medical record through various methods such as scanning, dictation/transcription, voice recognition, and/or templates via pen based or key board entry. Voice recognition can be the first step to implementing EMR, but independently does not qualify as an EMR.