Is Your Medical Record Available On The Computer For All To See?
A medical record is a reference for each patient containing valuable information about the patient like the patient's name, address, date of birth etc. The medical record also serves as a medical history for each patient and contains documentation regarding the patient's former illnesses, symptoms, diagnosis and treatments. Usually, medical records are maintained independently by each healthcare provider having an association with the patient.
The traditional paper-based medical records require a lot of time, space and effort to maintain, store and organize data. Handwritten notes serving as medical records created confusion due to illegibility and were prone to degradation with time. Besides this the filing and storing of piles of papers demanded a strict maintenance and book-keeping for the record keepers.
With the introduction of high-tech record keeping facilities, paper-based records are slowly getting replaced with their electronic versions. Initially, the cost to convert the paper-based medical records to electronic medical records is time consuming and costly but the benefits of the new versions outweigh the costs in the long run. While responding to a patient's needs and his history sheet, accurate and prompt accessible information is a must for every healthcare provider. Digitally stored data provides the facility for legible, neatly organized and multiple editing features. Hence, the switching to the digital world from conventional paper records provides tremendous advantages and functions.
Typically, an electronic medical record consists of three or four essential sections. A section is reserved for free writing about each patient so that the doctor can input whatever information he feels will be necessary later. Another section refers to the conclusions and any future plans for treatment. A structured section contains data which is template based or a comprehensive list of medical lingo or medical codes in the form of dropdowns. An optional pictorial feature like charts or graphs can be appended to the electronic records which are not editable but there could be notes made regarding the information found in the image in another section referring to the image. Pages from other places in the form of letters and bio tests, etc. can also be attached to a patient's medical record.
The primary advantage of electronic medical records is the ease of access and small storage space required. The electronic version of records facilitates an incredibly fast way to find a particular patient's record. This is possible because of the speed at which the digital world works as opposed to manual searching for documents. Specialized software companies in electronic medical records provide the functions of remote access of a patient's data over the Internet from anywhere in the world. This means that not only are the records easily stored and easily accessible, they can be called up from any place if there is a sudden problem with the patient when he is on the other side of the globe!
Related Tags: records, electronic medical records, medical records
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