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Introduction to the Electronic Medical Record (EMR)

Introduction to the Electronic Medical Record (EMR)
Gary L Williams
Western Governors University

Introduction to the Electronic Medical Record (EMR)
The new millennium has produced many changes in the world as we know it. Our national security which seemed to be impermeable has revealed its vulnerability to being breached. Remember September 11, 2001 when the hi-jacking of planes lead to the destruction of the Twin Towers in New York City, and severe damage the Pentagon in Washington DC. Now our Healthcare System has now moved into the information highway. How you may ask, through the introduction of the EMR. So will the EMR be safe and secure? Let us investigate. So just what is the EMR? There are many formal definitions but the one that stands out and will be used today is from the Healthcare Information and Management Systems Society (HIMSS). It states: The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. (HIMSS) Within this definition there is a multitude of system components. Think of it like the multiple Introduction to the Electronic Medical Record (EMR)

dividers that were found in the paper medical record. For instance, you may see headers like, medication record, order entry, nursing assessments, the plan of care, education, radiology, cardiology, etc. Under the medication tab lays the eMAR, medication history, and reconciliation. Each band with the click of the mouse will open a new file within this record. The design is formatted to follow a systematic flow with check boxes, drop down lists, or free text space to document the patient findings, activities, and assessments. The EMR will have many benefits for the entire healthcare team and the patient. By development and design with the assistance of key personnel, the EMR should flow and make documentation easier. By having a standardized flow and options to document the standards of care, documenting should become easier and provide more consistency. Take for example a urine description. You may see for color description amber, yellow, red, clear, or tea. Then cloudy, turbid, clots, or mucous followed by malodorous, sweet, or pungent. This will provide a means of potential measurement for Evidence-Based Medicine (EBM). How many patients with UTI receiving Bactrim DS have amber mucous pungent urine on a GU unit? Can you see the pattern? The EMR will assist in critical thinking as well. Your physical assessment for instance may be by body system or a complete head to toe assessment. These screens will assist the nurse in reminders of required documentation. The nurse may receive a task list for a certain procedure or required documentation of a high risk factor, such as fall precautions, to alert the bedside nurse or technician that the document is due or past due. Introduction to the Electronic Medical Record (EMR)

The EMR will provide real time data and reports from various disciplines within the healthcare facility. For instance, a Vancomycin trough was ordered at 0700 and its 0900 and the IV medication is due. By selecting the laboratory tab your result will be there in front of you before the dose is administered. The same can be expected of radiology imagining results, EKG, stress test reports, a bedside capillary glucose test done by the technician. No more...
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