What Is An EMR? About EMR Systems – Electronic Medical Records

what is an emr

An Electronic Medical Record (EMR) system is a software platform that allows the electronic entry, storage, and maintenance of digital medical data. From a patient perspective, it is a digital version of a patient’s medical information that would have previously been recorded in a paper chart. Sometimes the term Electronic Health Record (EHR) is used to describe data that includes medical info entered outside of an office or hospital visit. For purposes of this page, we’ll use the term EMR to describe the clinical and technical components of the software.

Before the days of EMRs, your medical info was usually entered by hand and by filling out forms in a paper chart binder. Paper charts had a designated order in which the medical information was organized. This is important to cover because the paper chart structure has influenced the workflow and layout of today’s EMRs. Here are the tabs contained in a paper chart:

Face Sheet

A face sheet is a quick view of the patient, containing basic demographic info such as age, gender, address and phone number. It also has an overview of the patient’s medical condition, allergies, and current medications. In an EMR, this overview may be called a Snapshot or Synopsis.

Medical Encounters

This includes events that have occurred in which you interacted with a care provider. Regular office visits, trips to the ER, immunizations, hospital stays, and even telephone calls to your doctor’s office are all encounters, and are recorded in your medical record.

Progress Notes

This is where the physician and other caregivers document their assessment, impressions, and other data observed during visits with patients.

Orders and Prescriptions

Any time a healthcare provider prescribes a medication, orders an X-Ray, or even advises you wear a knee brace- these are all orders and are documented in your medical record.

Test Results

Results from your lab tests, MRIs, or any other diagnostic tests will be in this section.

Other information and documents from other healthcare providers

This is where any miscellaneous documents or materials are kept. For a paper chart, it’s usually near the end.

 

Medical Documentation – What Gets Entered in the EMR

Now we’ll have a look at what gets entered into the EMR from the time you arrive at the physician’s office, until you check out. Because of the history and logical layout of a paper chart, most EMRs attempt to group electronic data in a similar order to the paper chart. Here is an example. Notice the blue tabs on the left indicating the sections of the electronic chart:

electronic-medical-records

 

Intake – Reason for Visit and Vital Signs

When you arrive in the exam room, the Medical Assistant will open your medical record, usually by clicking on your name from the schedule. They will then confirm what you are being seen for and document it. If you are being seen for abdominal pain, that’s exactly what they will enter in the EMR. It’s important to note that this is not a diagnosis, just a reported observation.Next, vital signs are taken. Federal regulations for Meaningful Use of Electronic Medical Records systems require at least the gathering of height, weight, and blood pressure.

Patient Reported Medications

The MA will then ask you what medications you are on and record them in the EMR. They should ask for name, dosage, strength, and frequency. In the EMR, there will be a medications area that has your current meds list, and a prescriptions area, which has the prescriptions that your doctor may write for you. These are separate areas in the EMR, and the MA typically just documents the reported meds you are taking.

Allergy Documentation

The MA will ask if you are allergic to any substances, foods, or medications. This is one of the most beneficial aspects of an EMR because the systems have built-in allergy and medication conflict checking. Later in the visit, if the physician tries to order a medication that would cause a reaction, they will get a warning.

Medical History and Surgical History

In some care settings, your medical and surgical history may be gathered by the MA, other times it may be gathered by the front desk during check-in. One challenge that still exists with a lot of offices is the tradition of having you fill out a paper form with all of your medical and surgical history, which then seems to go nowhere because you get asked again by someone who keys it into the EMR. This can be solved by having patients enter their history on a tablet or at a kiosk. Medical kiosks are in more and more places these days, but are not quite everywhere yet.

Smoking Status

Another regulatory requirement is to ask all patients about their smoking status and offer smoking cessation materials to current smokers. The MA will record this info into the EMR. We should note that everything entered is date stamped, which is important to meet regulatory requirements that are date sensitive.

The Physician Visit

At this point, the MA will probably log out or secure the PC that is hosting the EMR, or if they are on a tablet, they just leave the room with the tablet. The chart is either considered closed, or secured while you read last year’s magazines and wait for the physician.

When the doctor arrives, they will reopen your chart from the EMR, which will require some form of logging in to validate their identity. They will then take a minute to review the information that the MA entered. What I mentioned in the last section about data-driven regulations applies here as physicians are required to record that they have reviewed various parts of all patients’ medical records. This requirement is usually met by the physician clicking a “mark as reviewed/noted” button that is in several places of the medical record. That action is logged in the database as part of the official record.

Progress Note

The physician will at some point open a progress note section of the record to begin documenting the findings of the visit. Some doctors document while they are visiting with the patient, some start the progress note in between patients, and some document after the visit. It it also sometimes called a SOAP Note.

SOAP stands for Subjective, Objective, Assessment, and Plan. By the names of the sections, you may be able to guess a little about what is contained.

Doctors rarely type the entire contents of the progress note the way we type letters from scratch. Since many of their visits are very similar in structure, they rely on note templates to quickly document their findings. Doctors will usually have note templates for common conditions like flu, ear infections, and respiratory infections. They will also have note templates for certain types of patients, like for an adult physical or a well-child checkup.

Visit Diagnosis

Once the physician has determined the problem, they will enter one or more diagnoses in the EMR. This is not necessarily the same as the chief complaint- many times is isn’t. That’s why they’re the doctors and we’re not. The visit diagnosis is important in the medical record for many reasons, such as:

  • Billing: Insurance pays different amounts for different conditions, as we all know,
  • Research: If we have accurate diagnoses on many patients, that data can be used to better treat conditions, or even spot trends and potential epidemics.

Diagnoses all have codes that are recognized by clinicians and insurance providers. You may have seen them show up on insurance statements you get in the mail. For example, Type 2 Diabetes has a code of E11.9. An EMR enables physicians to just enter the English description of the code, and have the correct billing equivalent transmitted to insurance providers. Before electronic records, physicians’ offices had to manually keep track of billing codes, and frequently kept huge reference books on hand.

Problem List

Once as diagnosis has been made, the physician will determine if the condition is a long term or chronic condition, like Diabetes. “Flu” would not go on the problem list because it isn’t a long-term condition. Also, usually only the physician has the authority to update diagnoses on the problem list.

Level of Service

Level of service is a code that the physician enters into the chart to correctly bill for various levels of complexity of an office visit. For example, you may have two Diabetes patients; one is managing their condition well with few complications. The other patient is not managing their Diabetes well and has many complications. The more chronic patient visit would be coded to a higher level of service than the other visit.

Medications or Orders

The physician may order medications, lab tests, X-rays, referrals to specialists, or any number of other orders or procedures. Those all have to be entered into the EMR, and each order needs to be associated with the correct diagnosis. Those orders usually have expiration dates and are part of your permanent medical record for historical purposes.

Patient Instructions (After Visit Summary)

When the doctor is finished with the visit, they will usually print an after visit summary (AVS), which is the handout that you get stating what you were seen for and how to address the condition(s). The EMR vendor usually has a component of the software which imports the patient instruction information from a third-party provider of this material. Main suppliers of this integration are RelayHealth and Krames.

Final Medical Documentation Task

The last thing the physician does is to close the encounter in the EMR. This step is very important as many physicians are evaluated on percentage of closed encounters over time. Also, charges for the visit usually cannot be sent electronically to insurance companies until the encounter is closed. At this point, the front desk scheduler may also record the visit as checked out in the EMR.

Post Encounter Billing

While the clinicians are now finished with the encounter, there is usually an electronic transmission that goes to a billing and coding department. The coders will use a combination of software and human analysis to determine any corrections to the encounter before billing is sent to insurance. In some cases, there will be a clinician in the physician department who is also certified in coding. That person may amend the encounter to update the level of service or other billing related areas of the chart.

Scanned Medical Records

For this function, you may have some paper records from outside medical visits that are relevant to your current health that should be included in your record. Most EMRs have the ability to scan these documents into a designated section of the chart. While there is some usefulness to this approach, the contents of the documents is usually not searchable and tends to get forgotten. This is what we call “non-discrete” data, and it’s not the preferred way to capture data.

Conclusion

So you see that a well-implemented EMR system can gather all the necessary info that used to be carried in a paper chart but has a number of other benefits:

  • The ability to search for data just like you would a website or document,
  • A visual snapshot of the overall condition of a patient, in one view,
  • Backups of data that survive natural disasters which could obliterate paper records,
  • The ability to store data for detailed analysis of any number of medical conditions or other factors.

Next, check out a couple of related posts: We have a review of a popular EMR, as well as a career highlight on one of the key job roles involved with implementing these systems.

 

 

Summary
What Is An EMR?
Article Name
What Is An EMR?
Description
What is an EMR? An Electronic Medical Record system is software that allows for the entry, storage, analysis, and maintenance of digital health data.
Author
LearnHealthTech.com