NURSING MANAGEMENT

ASSIGNMENT
ON
ELECTRONIC MEDICAL RECORDS
 ELECTRONIC MEDICAL RECORDS
INTRODUCTION
 An electronic health record (EHR), or electronic medical record (EMR), is a systematic
collection of electronic health information about an individual patient or population. It is a record
in digital format that is theoretically capable of being shared across different health care settings.
In some cases this sharing can occur by way of network-connected, enterprise-wide information
systems and other information networks or exchanges. EHRs may include a range of data,
including demographics, medical history, medication and allergies, immunization status,
laboratory test results, radiology images, vital signs, personal statistics like age and weight, and
billing information.
 The system is designed to represent data that accurately captures the state of the patient at all
times. It allows for an entire patient history to be viewed without the need to track down the
patient’s previous medical record volume and assists in ensuring data is accurate, appropriate and
legible. It reduces the chances of data replication as there is only one modifiable file, which
means the file is constantly up to date when viewed at a later date and eliminates the issue of lost
forms or paperwork. Due to all the information being in a single file, it makes it much more
effective when extracting medical data for the examination of possible trends and long term
changes in the patient.
TERMINOLOGY
 The terms EHR, EPR (electronic patient record) and EMR (electronic medical record) are often
used interchangeably, although differences between them can be defined. The EMR can, for
example, be defined as the patient record created in hospitals and ambulatory environments, and
which can serve as a data source for the EHR. It is important to note that an EHR is generated and
maintained within an institution, such as a hospital, integrated delivery network, clinic, or
physician office, to give patients, physicians and other health care providers, employers, and
payers or insurers access to a patient's medical records across facilities.
A personal health record (PHR) is, in modern parlance, generally defined as an EHR that the
individual patient controls.
TECHNICAL FEATURES
 Digital formatting enables information to be used and shared over secure networks
 Track care (e.g. prescriptions) and outcomes (e.g. blood pressure)
 Trigger warnings and reminders
 Send and receive orders, reports, and results
 Health Information Exchange
  Technical and social framework that enables information to move electronically between
organizations
 Reporting to public health
 E-Prescribing
 Sharing laboratory results with providers
Goals and objectives
 Improve care quality, safety, efficiency, and reduce health disparities
 Quality and safety measurement
 Clinical decision support (automated advice) for providers
 Patient registries (e.g., “a directory of patients with diabetes”)
 Improve care coordination
 Engage patients and families in their care
 Improve population and public health
 Electronic laboratory reporting for reportable conditions (hospitals)
 Immunization reporting to immunization registries
 Syndromic surveillance (health event awareness)
 Ensure adequate privacy and security protections
QUALITY BENEFITS OF AN EMR
 Assessing data from paper medical records is time-consuming because it involves reviewing
information manually — record by record. By contrast, an EMR makes data easily accessible
and enables physicians to use their own data to improve quality of care. With efficient
electronic access to clinical data, practices can systematically improve the quality of care in a
number of areas:
 Enhanced patient education material: Practices can customize information packets and Web
site referrals for patients so that patients receive essential information about their health at the
point of care and guidance from reputable, scientific sources.
 Quicker turnaround times for results of lab tests and imaging studies: Connectivity
between practices and the clinical laboratories and imaging centers shorten the time necessary
for diagnostic information to reach the practice and the patient. Physicians can initiate therapy
more quickly and reduce patient waiting time.
 Improved diagnostic process: The availability of decision support at the point of service
fosters a consistent, evidence-based diagnostic process.
 Streamlined health maintenance and chronic disease management: EMR systems can
generate automated appointment reminders for periodic checkups and for monitoring chronic
 diseases and conditions. Monitoring patient responses to these reminders enables practices to
follow up with patients who need medical attention but are not responding to the practice’s
automated messages.
 Protocol-based treatment: EMRs have the capability to incorporate treatment protocols so
that physicians can track the care of individual patients within an evidence-based framework.
 Reduced medical errors: Intelligent e-prescribing alerts physicians to problems resulting from
drug interactions and allergies. It also can help physicians avoid errors caused by the very large
number of prescription drugs that have similar names.
 Improved access to patient records: EMRs improve access to patient information that is both
legible and up-to-date. EMRs can provide the physician electronic access to patient records
from remote locations whenever needed.
 Improved outcomes: The sum of all these individual parts is process improvement that leads
to better outcomes. The incorporation of evidence-based protocols, decision support, and e-
prescribing into the EMR gives the physician diagnostic and treatment-relevant information
during the patient encounter. The tools for improving practice and self-monitoring are
immediately at hand.

EFFICIENCY BENEFITS OF AN EMR

 The efficiency benefits of an EMR derive from three changes that occur in practices as they
move from paper to electronic:
o The reduction in expenses associated with the management of paper records;
o Significantly more efficient and accurate coding and billing of claims as a result of template-
based documentation;
o Redesign of workflow so that practice staff can become mor productive users of the practice’s
HIT system;
o Real-time access to a patient records from multiple computers and locations, including remote
access beyond the office, without physically retrieving a paper chart; and
o Multiple people simultaneously accessing a single patient record from multiple locations,
improving work flow in some situations.
GETTING RID OF PAPER
 Eliminating paper medical records saves both forests and money. Typically, practices report a
$25 savings per chart by eliminating the supply, copying, printing, and storage of paper charts.
Transcription costs generally drop by a range of 50 to 100 percent. Staff efficiency is greatly
 improved because the time-consuming task of physically moving paper charts around the office
is eliminated, and the time needed for ordering and tracking lab tests, imaging studies, and
prescriptions is greatly reduced.
TYPES OF EMR
Departmental EMR:
It contains information entered by single hospital department e.g.picture archiving and
communication system(PACS), Anesthesia Records, Intensive Care Unit Records, Ambulatory
Records, Emergency Departmental System, Internal medicine records, gynaecology records,
radiology reporting system.
Inter-departmental EMR:
This type of records contains information from two or more hospital departments.
Hospital EMR: It contains all or most of patient’s clinical information from hospital.
 Inter hospital EMR: Contains patient’s medical information from two or more hospitals.
 Electronic patient record: Contains all or most of patient’s information from a particular
hospital.
 Computerized patient record: This record contains all or most of patient’s clinical
information from a particular hospital.
 Electronic health care record: Contains all patient health information.
 Patient health record: This record is controlled by the patient and contains information at least
partly entered by the patient.
 Computerized medical record: These type of records created by image scanning of a paper
based health record.
 Digital medical record: A web based record maintained by a health care provider.
 Electronic client record: Scope is defined by health care professionals other than physicians,
e.g.by physiotherapist or social worker.
 Virtual HER: It has authoritative definition.
 Population health record: These records contains aggregated and usually de-defined data.
THE ELECTRONIC HEALTH RECORD
 The electronic health record is a longitudinal electronic record of patient’s health care
information generated by one or more encounters in any care delivery setting. The information
is patient demographics, process notes, problems, medications, vital signs, immunizations,
laboratory data and radiology reports.
 The EMR automate and steam lines the clinicians work flow. The EHR has the ability to
generate a complete record of a clinical patient encounter as well supporting other care related
 activities directly or indirectly via interface including evidence based decision support, quality
management and outcomes reporting.
TYPES OF ELECTRONIC HEALTH RECORD
1. Automated medical record: This is a paper based record with some computer generated
documents.
2. The computerized medical record: This type of electronic record makes the documents of
level 1 electronically available.
3. The electronic medical record: This type of record restructures and optimize the documents of
the previous levels ensuring inter-operability of all documents system.
4. The electronic patient record: This is a patient centered record with information from multiple
institutions.
5. The electronic health record: In this type of record general health related information in
addition to the EPR that is not necessarily related a disease.
STRUCTURE OF EHRS
The structure of EHRS is time oriented, problem oriented and source oriented but these days
EHRS combines all these elements.
 Time oriented EHRS: In this type of EHRs the data are presented in chronological order.
 Problem oriented medical record: In the problem oriented medical record notes are taken for
each problem assigned to the patient and each problem is described according to the subjective
information, objective information, assessments and plan.
 Source oriented: In the source oriented record the content of the record is arranged according
to the method by which the information was obtained. E.g. notes of visit, X-ray reports and
blood tests.
COMPONENTS OF EHRs:
The components of EHRs are,
 Medical data components
 Nursing data components.
MEDICAL DATA COMPONENTS:
 The identified medical data components of EHR consists of referral, present complaints,
symptoms, past medical history, lifestyle, diagnostic tests, procedures, treatments, medication
and discharge.
NURSING DATA COMPONENTS:
 Nursing data components of HER comprise of nursing charting area and nursing care plan,
medication administration, daily charting, physical assessment and admission nursing notes.
  Medication administration includes the treatment given to the patients its time of administration
etc.
 Daily charting includes patients daily functional activities such as vital signs, food, elimination,
mobility, patient teaching.
 Physical assessment comprise all kinds of status assessments .g skin status or respiratory status.
 Admission nursing notes contains information on allergies, health behavior, physical
assessment, discharge planning and initial care plan.
OTHER ELECTRONIC RECORD DEVICES
Personal digital assistants
PDA are literally handled computers that help patient management. The users of PDA are,
 To access a patient’s laboratory reports and refer the latest information on relevant therapies,
tests and treatment.
 To use for billing and updating patient visits.
 To provide map and directions to the patients homes.
Computer automated cancer detection
 Computer automated cancer detection like Thinprep processor model 2000 or PAPNE are used
for identifying abnormal cells from a series of digital images of PAP smears fed.
Computerized theatre management application
 Theatre management applications automatically record patient information like demographic
and financial data, visit history with dates, procedures, performing and attending providers, care
records with clinical highlights and patient status, surgical data including proposed, type, actual,
severity and risk stores for reference in the event of future surgical procedures.

COMPONENTS AND USERS OF EHRs:

 Daily charting, medication administration, physical assessment,

NURSE admission nursing notes, nursing care plan.

 Referral, present complaints, past medical history, lifestyle,

diagnosis, tests, medication, discharge.
DOCTOR
 ELECTRONIC MEDICAL RECORDS MAINTAINNING IN URBAN HEALTH POST-
SELLUR
 Electronic medical records are maintaining in urban health post for various purposes. These
includes the patients data entry, services in the urban health post, census for monthly and daily,
report from each village health nurse, drug stock and indents, staff salary details and so on.
 The data which is collected from the patients and staff entered in to the computer in special
website sending to the directorate of health and family welfare. The website is fully confidential.
The username and password for the website can only accessible to the village health nurse and
staff nurses in concerned urban health post. Laptop and modum provided for each village health
nurses and they will be sending report to directorate every afternoon.
ELECTRONIC MEDICAL RECORDS:
 ELECTRONIC ANTENATAL POSTNATAL RECORD
 ELECTRONIC INFANT ENTRY RECORD
 ELECTRONIC NCD RECORD
 ELECTRONIC OUT REACH SERVICES RECORD
 ELECTRONIC PHARMACY RECORD
 ELECTRONIC FAMILY WELFARE PROGRAMMES RECORD
 ELECTRONIC SCHOOL HEALTH PROGRAMMES RECORD
 ELECTRONIC NATIONAL PROGRAMMES RECORD
ELECTRONIC ANTENATAL POSTNATAL RECORD
  Antenatal mothers are registered in the website known as that will generate the number which is
the registration number for the mother. The data of the antenatal mothers are entered into that
page like age, sex, weight, height, hemoglobin level, present complaints, immunization status,
iron and folic acid supplementation, high risk pregnancies. The mothers who are receiving iron
sucrose infusion will be entered separately.
ELECTRONIC INFANT ENTRY RECORD
 Under five children census, height, weight, mid arm circumference, growth chart, immunization
as per the schedule are registered in the computer. Every Wednesday afternoon entering the
immunization detail into directorate through the electronic mail.
ELECTRONIC NCD RECORD
 Number of new cases are identified in non communicable diseases like diabetic mellitus,
hypertension and cancer cervix and number of old cases and their treatment were entered in to
website every day afternoon.
ELECTRONIC OUT REACH SERVICES RECORD
 Outreach camps and special programmes report are entered into the website by the concerned
staffs. The venue of camp, response of public and achievement should mentioned in the report.
ELECTRONIC PHARMACY RECORD
 The drug issue record, indent record, stock record and expiry medicine records are separately
mentioned in the pharmacy column. The transfer of medicine and storage also mentioned in the
website.
ELECTRONIC FAMILY WELFARE PROGRAMMES RECORD
 National family welfare programmes like maternal and child health, national rural health
mission, janani suraksha yojana, muthulakshmi reddy scheme beneficiaries are entered into the
respective pages. The number of ICD insertion, usage of contraceptive pills also entered in the
system.
ELECTRONIC SCHOOL HEALTH PROGRAMMES RECORD
ELECTRONIC NATIONAL PROGRAMMES RECORD
The report of school health programmes and the other programme reports are entered in the same day
itself in the computer.
CONCLUSION
 Electronic Medical Records (EMRs) have revolutionized modern healthcare by improving the
accuracy, accessibility, and coordination of patient information. Their integration into clinical
practice has led to enhanced patient safety, reduced medical errors, and streamlined workflows.
Despite some challenges such as initial costs, training, and concerns over data security, the long-
 term benefits of EMRs are significant. With continuous advancements in technology and
increased focus on interoperability and privacy, EMRs are poised to become even more integral
in delivering high-quality, efficient, and patient-centered care.

REFERENCES
1. Gartee, R. (2011). Electronic health records: Understanding and using computerized medical
records (2nd ed.). Pearson Education. A foundational textbook that explains the structure, use,
and management of EMRs in clinical settings.
2. Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses and healthcare
professionals (6th ed.). Pearson. Covers nursing informatics, with chapters dedicated to
electronic records and their practical application.