Simone Lawson
Electronic Health Records (EHRs) are digital versions of patients' medical histories, maintained and updated by healthcare providers. EHRs have become integral to the medical industry, improving patient care and maximising efficiency. They include key administrative and clinical data, such as demographics, test results, medications, progress notes, vital signs, past medical history, immunisations, and laboratory data. These records are easily accessible, enabling quick access to patient information, improving patient-provider communication, streamlining workflows, and supporting informed decision-making in healthcare. The benefits of EHRs also extend to cost savings, improved safety, and enhanced coordination of healthcare services.
| Characteristics | Values |
|---|---|
| Medical History | Demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, radiology reports, test results |
| Accessibility | Accurate, up-to-date, quick access, securely shareable |
| Efficiency | Streamlined workflow, improved coordination, reduced duplication of testing, reduced paperwork, reduced costs |
| Patient Care | Improved safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity |
| Public Health | Encouragement of healthier lifestyles, increased physical activity, better nutrition, avoidance of behavioral risks, wider use of preventative care |
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What You'll Learn
Patient demographics
An Electronic Health Record (EHR) is an electronic version of a patient's medical history, which is maintained by the provider over time. It includes patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports.
Practices commonly collect patient demographic information through registration forms or health apps. This information is used to improve care and communication, streamline the medical billing and coding process, and guide healthcare decision-making. For instance, demographic information can help healthcare providers understand if certain demographic groups require more attention or specialised care.
It is crucial to ensure that patient demographics are collected accurately, routinely updated, and securely maintained to comply with patient privacy regulations, such as HIPAA in the United States. Innovations in mobile health (mHealth) offer opportunities to enhance the management of patient demographics, allowing patients to update their information conveniently from anywhere, at any time.
Overall, patient demographics play a vital role in the healthcare system by facilitating patient identification, improving the quality of care, and enabling healthcare providers to make informed decisions that meet the diverse needs of their patient population.
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Progress notes
An Electronic Health Record (EHR) is an electronic version of a patient's medical history. It is maintained by the provider and includes administrative and clinical data such as demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports.
The length and content of progress notes can vary depending on the specialty and the individual provider's practices. For example, ophthalmology progress notes tend to be lengthy, with a high percentage of copied or imported text. This can make it challenging for physicians to find key sections and important information. To address this issue, it is important to analyze the content and structure of progress notes to inform best practices and EHR design recommendations.
Studies have shown that the majority of the text in EHR progress notes is copied or imported rather than manually entered. While this simplifies the documentation process for clinicians, it can also increase the risk of including outdated, inaccurate, or unnecessary information. To mitigate these risks, it is important for clinicians to carefully review and update copied or imported content to ensure its accuracy and relevance to the patient's current condition.
The use of EHR progress notes offers several advantages, including improved accuracy, efficiency, and coordination of patient care. EHRs enable quick access to patient records, facilitate secure information sharing, and enhance interaction and communication between patients and providers. Additionally, EHRs can help reduce costs by decreasing paperwork, improving safety, and reducing duplication of tests.
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Medications
An Electronic Health Record (EHR) is an electronic version of a patient's medical history. It contains all the key administrative and clinical data relevant to a patient's care, including their medication.
The medication section of an EHR contains information on the patient's prescriptions, including the type of medication and the dosage. This information is vital for patient safety, as it helps clinicians make informed decisions about a patient's care. For example, an up-to-date medication list can help prevent adverse drug interactions or allergic reactions. Additionally, the medication section of an EHR can also include information on the patient's medication history, such as any medications the patient has taken in the past, as well as any known allergies or adverse reactions.
While EHRs provide valuable information on medication prescriptions, it's important to note that they may not always include the reasons for prescribing a particular medication. This information may be found in clinical notes or outpatient records. However, natural language processing techniques have been developed to determine the reasons for medication prescriptions based on information in outpatient notes, improving patient safety.
The medication section of an EHR can also be used to support other care-related activities, such as medication adherence and patient education. For example, patients can securely access their medication list through patient portals, helping them keep track of their medications and improve adherence. Additionally, EHRs can provide educational resources and instructions on taking medications, improving patient understanding and empowerment.
Overall, the medication section of an EHR is a critical component of a patient's medical record, providing valuable information on their prescriptions, medication history, and relevant clinical data. It helps ensure patient safety, supports clinical decision-making, and empowers patients to take an active role in their healthcare.
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Test results
An Electronic Health Record (EHR) is an electronic version of a patient's medical history, maintained by the provider over time. EHRs contain a patient's test results, which are an important part of their health care. Test results are obtained by checking samples of a patient's blood, urine, or other body fluids or tissues. These results are then transmitted to the patient's EHR, where they are stored and can be accessed by healthcare providers to inform diagnoses and treatment plans.
Laboratories play a crucial role in ensuring the accuracy, completeness, and formatting of test results transmitted to EHRs. They must verify the information, including results from in-house and reference laboratory tests, before sending it to the EHR. This process involves manual entry or the use of laboratory information systems (LIS) and middleware programs. The accuracy of test results in EHRs is essential for effective patient care and can impact diagnosis, treatment, and patient safety.
To validate the accuracy of test results in EHRs, studies such as the College of American Pathologists' (CAP) Q-Probes Study have been conducted. Participants in this study reviewed results from multiple laboratory tests directly within the EHR. They compared the numeric or textual results in the EHR with other sources, such as LIS, paper worksheets, instruments, or other primary sources. This process helps ensure the reliability and validity of the test results in the EHR.
While test results are crucial, they do not provide a complete picture of a patient's health. Healthcare providers must consider test results alongside other information, such as physical exams, health history, family health history, and imaging tests. By integrating multiple sources of information, providers can make more accurate diagnoses and develop comprehensive treatment plans. This holistic approach ensures that patient care is tailored to the individual and considers all relevant factors.
In conclusion, test results are a vital component of EHRs, providing valuable data for healthcare providers. The accuracy and reliability of these results are ensured through rigorous laboratory processes and validation studies. By combining test results with other aspects of a patient's health, providers can deliver effective, safe, and personalised care. EHRs streamline the accessibility of test results, facilitating improved patient care and enabling providers to make well-informed decisions.
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Vital signs
An Electronic Health Record (EHR) is a digital version of a patient's medical history. It is maintained by a healthcare provider and includes administrative and clinical data relevant to a patient's care. One of the critical components of an EHR is vital signs.
- Body temperature
- Heart rate and rhythm
- Blood pressure
- Respiratory rate
- Oxygen saturation
These vital signs offer valuable insights into the patient's cardiovascular, respiratory, and thermoregulatory systems, helping clinicians make informed decisions about their care.
The documentation of vital signs in EHRs is a complex process. It requires a detailed understanding of the clinical workflow and how different facets of interface design impact clinician performance and cognition. The design of EHR interfaces plays a crucial role in relieving the cognitive burden on clinicians. Optimizing the organization of patient information and improving the accessibility of displays can enhance the efficiency of the documentation process.
The analysis and understanding of EHR-mediated workflows in the context of vital signs are crucial for the effective adoption of health information technology. By scrutinizing the aspects of vital signs charting interfaces and investigating variations in documentation across clinical sites, improvements can be made to enhance the overall patient care experience.
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Frequently asked questions
An EHR is an electronic version of a patient's medical history.
An EHR includes administrative clinical data such as demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports.
EHRs improve patient care and maximize efficiency. They also improve patient safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity.
EHRs help providers better manage care for patients by providing accurate, up-to-date, and complete information about patients. They also enable quick access to patient records, reduce medical errors, and improve patient and provider interaction.
EHRs help reduce costs by decreasing paperwork, improving safety, and reducing the duplication of testing. They are also much less expensive to store and transmit electronically than hard copies.
