What Does An Electronic Medical Record Include?

A patient record can come in many different forms depending on the healthcare organization or medical practice that issued it, but it should still contain the essential health data required for medical professionals to use to improve patient outcomes. Whether it's a primary care doctor referring to a specialist or a physician handling a cosmetic case gone wrong, a patient health record is a must-have, especially if it's in electronic form.

But what exactly does an electronic medical record include? Basically, an EMR is a digital version of a patient's chart in a practice. It contains everything relevant to the patient's care and treatment within that specific practice, including details about the prescriptions they have, the medical routines they undergo, and their diagnoses. An EMR can be accessible by doctors only, but can also be distributed to patients via a patient portal.

What's Inside An Electronic Medical Record?

One thing to note about an EMR is that because of the different specializations and practices in the healthcare industry, the exact format and information that you can find in one EMR can differ from the next. Depending on the EMR vendor, these differences can easily be integrated into your EMR system without much difficulty.

However, here are the absolute essentials that every electronic medical record should have:

1. Your Patient's Medical History

Above all else, the most important things about your patient's medical history should be in an EMR. Their condition, official diagnosis, treatment plans, and other medical procedures done on them should always be clearly stated and visible in an EMR, as it's the first thing that your physician or doctor will be looking for as soon as that patient walks into your practice.

Keep in mind that this medical history may not always reflect their entire journey through the healthcare industry, but it should succinctly reflect the immediate concerns that your medical staff may have about your patient. Issues like allergies, drug interactions with any medicines they may be taking, or their treatment schedules should be clearly stated in their EMR for easy access at a glance.

Learn more: What Is the Medical Record Retention Period?

2. Your Patient's Prescriptions

One of the primary uses of a patient's medical record is to keep track of any prescriptions that your doctor may have recommended to your patient. Using an EMR system makes this easy to review and evaluate every step of the patient's treatment plan, and is an extremely useful record for all medical staff to consult if said patient ever develops a complication relating to the medicine that they're taking.

An EMR can also be useful for your patient if they misplace their own prescriptions since it can function as a verifiable prescription that they can present to their pharmacy if they accept electronic records. This can be potentially life-saving if the patient needs a specific medication but hasn't brought the prescription for it: the accessible nature of EMRs (especially through a patient portal) can drastically improve patient outcomes in these situations.

3. Your Patient's Lab Results

For patients that have been confined to a medical institution or practice long term or simply have a lot of tests to go through for a diagnosis, EMRs are useful tools in helping doctors keep track of any past and upcoming tests they may have. This is useful across a wide range of different situations in medical practice, but it's also a simple way of keeping crucial health data accessible to cross-check any lab or test results against new diagnoses or developments on your client's condition.

Since an electronic health record can be updated in real-time, your patient can be processed faster and more efficiently compared to waiting for the paper records to catch up between different doctors and different tests. This is crucial in situations where the patient needs their test results quickly for a diagnosis, or simply to release a patient from your care if their condition has already been addressed. Either way, an EMR can drastically cut down the wait times of processing a patient through different tests and is a handy record to keep around your practice for future reference.

4. Your Doctor’s Notes

A doctor’s notes can take many different forms depending on the patient and their condition, but they’re always useful to consult in cases where the patient may be experiencing a rapid shift in their condition or are looking for referrals to specialists for better patient care. Doctor notes are crucial pieces of health data that can inform the patient, other doctors and medical professionals, and even members of your staff about the status of a patient and how much priority and attention they should be giving for their medical treatment.

One of the most common doctor’s notes that can be found in an EMR is SOAP notes (Subjective, Objective, Assessment and Plan), a widely-used documentation method for healthcare workers that can give a brief yet illuminating overview of the patient at the time of consultation. Consistent SOAP documentation of a patient throughout their stay in your practice or institution offers a much better view of how their care is progressing, and whether any changes need to be made.

Since most EMRs are only limited to the actual practice or medical institution that the patient is currently going to, the information on them tends to be brief and straight to the point. If you’re looking for a more comprehensive overview or method of keeping track of a patient’s medical treatment, you may be looking for an electronic health record.

Read more: Are All Medical Records Linked?

EMR vs EHR

The difference between an electronic health record (EHR) and an electronic medical record (EMR) is quite simple: EHRs are simply better versions of EMRs. Not only do they contain an extensive overview of a patient’s medical history, diagnoses, and treatments, but they’re structured in such a way that allows easy sharing of information between medical professionals and practices. Using an EHR system or EHR software can help a receiving practice better care for a transferred patient, or impart useful notes when referring them to a specialist.

One thing to note about EMRs and EHRs is that both of them still fall under the Health Insurance Portability and Accountability Act, which means that you need to check the exact ruling about sharing your patient’s medical information with any third parties, even if it’s another health care provider. Failure to comply with the HIPAA privacy rule can result in severe sanctions for your medical practice and may be grounds for legal action from your patient.

Learn more: What Is the Difference Between an Electronic Medical Record and an Electronic Health Record?

Secure Electronic Medical Records With EMR Software

Patient medical records can vary depending on the healthcare provider, but certain essentials should always be present in an electronic health record. By keeping health information in an easy-to-access platform like EMR software, it becomes easier for health care providers to improve their patient care and safeguard a patient's medical history and patient data.

Calysta EMR helps improve patient engagement by providing a healthcare facility or medical practice with an electronic record of their patient's care and personal health record. Aside from improving your practice's HIPAA compliance, we can also help your clinician or physician find crucial medical information about their patient without having to consult a paper medical record. For more information on our EMR system and how we can help with your patient's EHR, contact us today.