Traditional Medical Records vs Electronic Medical Records
A paper patient record is recognized by name, serial, membership, reference or medical record number, and other identifiers that make it easier to find in the physical filing system. It takes long time to sort thousands of files, whenever patient or doctor requires checking previous medical history or updating the status of record. On other hand, an EHR provides dissimilar identifying information for each patient, and identifiers to locate the digital record among any number of records. Due to its digital nature, finding patient record is concern of merely seconds.
If a paper chart is filed correctly in the medical records system, a staff member must go to the stacks of charts, using some quick identifier code. After matching the exact last name and first name, then the chart is "pulled" for desired review. Sometimes, a placeholder is inserted in stack, to make re-filing easier and for reference where the chart is headed. In this whole manual process, there is great potential of human mistake; any file can be lost easily due to slight negligence. An electronic chart is never lost, out, or misfiled because it is always exactly where it should be. An electronic record may be accessed from any point in a healthcare facility that has access to medical records.
A paper medical record includes office or progress notes in chronological sequence. These are sorted and searched by flipping through pages, until the desired entry is located. Progress notes in a traditional paper record might be produced by dictation/transcription, free handwriting, or form completion method. An EHR keeps progress notes and provides quick access by date of visit, provider or other accessible search criteria and the ability to browse by diagnosis and prescription. A full function EHR automatically creates the progress notes, as the visit is produced.
Laboratory and radiology reports, as well as related communication, are filed in more or less chronological order. Access to specific/desired entries can be prolonged or slow. An EHR stores reports/information in number of ways to provide quick access and speedy reference, such as scanned images, direct lab results or even on-line laboratory information. Access to common demographic and information is highly resourceful and useable due to implementation of EHR system in any practice.
In a paper chart system, a healthcare provider typically writes a paper prescription for the patient to take to a pharmacy. Actually, once this information has been adequately obtained, the paper prescription is handed to the patient. It is then necessary for the provider to document the process (that just took place), including the negative potential for drug interactions and allergies, as well as the form, strength, quantity, and directions for the prescribed drug/medicine. On other hand, EHR with strong clinical