Electronic Health Record

1. Types and content of health records Medical Records or Health Information Management records are meant for organizing patient’s health data by ensuring accuracy, quality, accessibility, and security What are Medical Records? In modern medical industry, the terms health record and medical record are used interchangeably, both meaning the documentation of a patient’s complete medical details such as medical history and health care over a period of time that covers the person’s lifetime. Medical Records include various types of notes as entered by the treating physician or service providers, describing their observations, therapies and procedures performed, and medications. In addition, medical record consists of tests and results, x-rays and radiology reports, and family history. Health records may be maintained in the form of the provider’s preference. Electronic Health Record

2. Broad Classification of Medical Records According to the format in which they are maintained, medical records may be classified as follows: Paper-based Medical Records: This is the normal type of traditional paper chart one gets to see at the physician’s place – this is getting obsolete and is widely being replaced with digital records Hybrid Records: In this type, patients’ medical information is stored partially on paper with the other portion being stored on the computer – this creates difficulty in finding all data at one instant, as data is split and stored in different places Electronic Health Records: Promising accuracy and offering easy access, this technology-driven modern tool is sure to revolutionize medical record management and health care quality. By providing a collective and all-in-one view of various health information pertaining to a patient drawn from varied providers, Electronic Health Record (EHR) ensures that patients and providers are able to reach crucial medical information when and as required. Content of Electronic Health Record (EHR) Software A typical EHR must include the following: Personal Data Name & ID number Birth date Contact address and phone number Marital status Details of primary care physician Allergies and drug reactions Medical Data History & Physical Consultation reports

3. Test and Diagnostic results Problem List and Progress Notes Immunization and Allergy Documentation Health screening details Discharge summary Apart from the above said details, EHRs also include the following data: Reason for practice visit Problem duration Physical examination’s findings X-ray & Radiology reports Medication and dosage details Follow-up plan, if needed Depending on the medical service provider and the individual, health information must be furnished in a way that assists the treating physician in coming up with the best methods of managing the patient’s health. Electronic Health Record needs to be comprehensive and self-explanatory so that they ensure providers are enabled to deliver the best health care and patients are assured of their safety. 6,First Floor, Vinayaga Avenue, Okkiyampettai, Old Mahabalipuram Rd, Chennai,Tamil Nadu 600097 Ph: +91 95666 74450 support@75health.com