The Six Functions of Electronic Medical Records

Electronic Medical Records are going to be needed in the future. It is important to learn the functions of EMR and how it fits into an office work flow.

1. Patient Charting

Patient visit information is put into templates or forms; to contain information such as vitals, complaints, medical histories, review of systems, physical exams, etc. Most EMR systems have pick lists, drop-down boxes, handwriting recognition, or voice recognition to accomplish patient charting.

2. Order Communication Systems

This is often referred to as a Computerized Physician Order Entry (CPOE). This allows the Electronic Medical Records system to communicate information with external systems such as laboratories, imaging centers, hospitals, and pharmacies via Health Level 7 Interfaces. This allows providers to send out lab requests, imaging requests, prescriptions, submit visit charges, and diagnosis codes to the office/billing system.

3. Clinical Decision-Making Support Systems

Alerts, reminders, and recommendations are built into the system allowing automatic clinical decision making with information in the database. It also helps doctors with coding and diagnosis. Many EMR systems provide physicians with a recommended CPT code based off of Evaluation and Management (EM) rules. This allows physicians to bill payers at the highest possible rate for the services performed.

4. Document/ Image Management

It is important for offices to manage the enormous flow of paper entering their office. Offices are constantly flooded with patient intake forms, referring physician letters, lab reports, and faxes. EMRs allow doctors to access these documents on a intuitive user interface. EMRs provide physicians a way to manage images such as x-rays, MRIs, and ultrasounds.

5. Patient Portal

Personal health records allow patients to access their health record from any computer with a secure internet connection. These programs include features such as appointment scheduling, refill requests, electronic intake forms, record access, outcome assessments and patient education. The patient can also grant other providers access to this information which allows provider-to-provider communication.

6. Statistics and Reporting

Providers can create reports from databases for statistical purposes. This becomes especially useful in the case of drug recalls, health maintenance reminders and disease management.

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Medical Records Tracking Software a Boon to Healthcare Professionals

If you keep medical records in your office, you are aware of the many challenges that you face. A good database and appropriate tracking software can help you overcome those challenges.

Your office may be modern and up to date in many ways. You may be using computer programs for scheduling patients and alerting the staff when follow-ups are needed. You probably have a system for electronic billing and, surely, all of the codes for billing Medicare or Medicaid can be found with a simple mouse click or a touch of a button.

You might have even cut down on the amount of paper used in your office by using the latest electronic medical records. But, if you have been in practice for a while, you likely have filing cabinets full of paperwork from years past. These files may contain everything from exam notes to X-rays.

Your patients have rights concerning these files. You must be able to access and provide their information quickly. Sometimes, there is no time to manually look through these files. That is when tracking software becomes particularly helpful.

RFID (radio frequency identification) tags can easily be attached to all of your current and out of date files. You can use the tags in your office to keep up with your patients during their stay, find out what medications they are taking quickly and track any lab work going out or coming in.

RFID tracking software is being used to reduce the risk of lost files and locate them easily. Doctors and other healthcare professionals are using the systems to track and report inventories. They find that the systems enhance staff compliance and boost productivity.

By reducing the amount of time that office staff spends searching for medical records there is a net gain of billable hours. It is possible to see more patients per day when everything runs smoothly and efficiently.

The advantage to your patients or clients is obvious. They experience less waiting, which to your staff means fewer complaints.

These systems can easily be worked into your existing database, assuming that it is up-to-date. The staff can easily learn how to use the systems. As time has gone by, the usability of the programs has improved greatly.

If you decide to implement the use of RFID tags, you will find that the tags are small, inexpensive and easy to attach to your files. Database and tracking software design teams provide support for you and your staff to ensure that everything continues to operate as it should and you can find your medical records when you need them.

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