Health care professionals and facilities use electronic medical records, or EMR, across the globe. Information such as a patient’s medical history, medication list, test results, allergies and insurance details are kept in an EMR. Physicians, hospitals and long-term care facilities all utilize EMR to keep track of patients. They are easy to update and can be accessed quickly. EMR can be shared among a variety of health care professionals, allowing all those caring for a patient to stay up-to-date with the patient’s condition. They also allow all health care professionals to see what is being done to treat the patient such as testing, prescription medication and restrictions.
Instructions
1. Choose and install EMR computer software that is compatible with the computer system being used by the health care provider. Software can be purchased both online and from software companies. Install the software onto the computer system. Consult an IT specialist to answer questions or resolve problems. Teach staff members how to use the new software. Allow employees to become familiar with the program prior to its use in the office to prevent complications during the conversion.
2. Assign user IDs and passwords to employees that require access to an EMR. Physicians, nurses and billing specialists are examples of the employees who will need user IDs and passwords. Teach staff how to log on to the system. Give them instructions on how to create, change and delete EMR files. Explain to employees how restrictive access works if applicable. Show employees how to enter patient information into the system to create an EMR file.
3. Gather the information needed for each patient’s medical record to be included in the EMR. Information such as patient demographics, medical history, allergy lists, medication lists, diagnostic testing, test results and insurance details should be included in an EMR for each patient seen by the health care professional. Most information should already be in the patient’s hard copy medical record. Any additional information needed must be obtained from the patient. Copies of documents signed by patients, such as permission-to-treat consent forms, can be scanned and included in the patient’s EMR.
4. Enter each patient’s information into the computer program to create an EMR. Be sure to include all known information about the patient. Create sections for each type of information entered in the file. Label each section of the EMR with a title describing the information found in that section. For example, enter all of a patient’s medications into the section marked “medication.” Use flags or special markers to highlight important pieces of information, such as a patient’s allergies, found in the EMR. Proofread each EMR prior to use to ensure that the correct information has been entered for each patient to prevent errors.
5. Update patient EMR as needed. Log in to the program, pull up the patient’s file and enter additional information. Changes to a patient’s file should be made immediately when new information such as a change of address or insurance company is obtained. This ensures that the correct patient information is in each EMR and helps prevent information from being lost. If making changes to a patient’s file must be delayed, be sure to put the new information in a noticeable place so it may be changed in the file when time permits or at the end of the business day. Proofread all changes prior to saving them into the file to prevent errors and typos.
6. Assign restrictive access to ensure that patient privacy remains intact. Some staff members, such as physicians and nurses, will require full access to a patient’s EMR in order to gather information needed to care for the patient. Full access to an EMR allows staff members to view all parts of the patient’s record. They are also permitted to add, change or delete information in the file. The billing department staff may be assigned partial access to an EMR. This means those employees will only be able to access information relative to their job. For example, the billing staff will only be able to access the part of a patient’s EMR containing their billing information and demographics.
