Patient record systems like electronic medical records (EMRs) and electronic health records (EHRs) digitize patients' clinical information to improve care. EMRs contain data from within a single facility like a doctor's office, while EHRs aggregate data across settings. EHRs offer broader access to records for authorized providers and support care coordination but require consistent standards and protections for privacy and security.

2. Patient record system is the digital version of the
clinical information regarding a patient.
It involves collecting, storing, manipulating and using
the available clinical information in delivering care to
the patient.
Patient record system includes:
1. Electronic medical record (EMR)
2. Electronic health record (EHR)

3. ❖To capture data at the point of care
❖To integrate data from multiple internal and external
sources
❖To support caregiver decision making. Core
capabilities

4. ❖Paper charts are not interactive and properly designed.
❖Printed reminders and cautions can be easily
overlooked.
❖Illegible handwriting – as less as 65% of the written
medical charts can be fully read.
❖Data can’t be shared with other important health care
personnel.
❖Take a lot of space for storage
❖Any disorganization or disaster in the office can lead to
data loss.

5. ❖The EMR can be defined as the digital version of
the patient’s chart created in hospitals and
ambulatory environments.
❖It is a digital version of the traditional paper based
medical record of a patient within a single facility
such as doctor’s office or clinic .
❖EMR act as a source of data for the electronic
health record (EHR).

6. 1. Diagnosis.
2. Treatment, medications & lab tests.
3. Allergies.
4. Physician , nurse and other clinician’s note.
5. Flow sheets ( vital signs, input and output,
problem lists)
6. Peri-operative notes.
7. Discharge summaries

7. Electronic health record (EHR) are the systematized
collection of patient’s records in a digital format that
makes the information available instantly and securely
to the authorized users across different healthcare
setups.
It includes patient’s demographics, medical history,
medication and allergies, immunization status,
laboratory test results, radiology images e.t.c

8. 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
different facilities.

9. •EHR
•Patients registration ID
•Radiology (Xray, CT scan)
•Biochemistry, Laboratory investigations
•Disease classification and index
•Scanned documents/ previous medical records
•Clinical data, treatment orders, results and OPD visits

10. Immediate access to key information - such as patients'
diagnoses, allergies, lab test results, and medications -
would improve caregivers' ability to make sound clinical
decisions in a timely manner.
Ability to quickly access new and past test results would
increase patient safety and the effectiveness of care.
Enables health care organizations to respond more
quickly to federal, state, and private reporting
requirements, including those that support patient safety
and disease surveillance.

11. Intuitive formatting and enhanced interaction
Eliminates unnecessary procedures of record
keeping , inventory and storage.
Facilitates data sharing.
No risk for data loss.
Helper applications can provide patient specific
feedbacks.
Easy to monitor and evaluate the treatment and
progress.

12. Provides alerts to the doctors regarding health care
needs of the patient.
Helps in conducting relevant research studies.
Collaboration between the patient and the doctor.
Empowers patient in the self management of
chronic disease by home monitoring and self testing.
Helps in tracking previous treatment of the patient.

13. Requires more time in data entry.
Reduced productivity
Needs expensive software and computer purchase.
Software maintenance is required.
Depends upon reliable operation.
Needs education and training of the staff.
Governance, privacy and legal issues
Records that are exchanged over the internet are
subject to the same security concerns as any other type
of data transaction over the internet.

14. How do electronic
medical record (EMR)
differ from electronic
health record EHR ??

15. ❖An EMR is a narrower view of patient’s
medical history, while HER is more
comprehensive report of the patients overall
health.
❖An EMR is mainly used for diagnosis and
treatment in a given health care setup. An
EHR is an overall report regarding patient’s
health condition.

16. ❖EMRs are not designed to be shared outside the
individual practice. EHRs are designed to be shared
with different authorized health care providers and
staff in more than one organization.

17. 1. Integrated systems require consistent use of standards
in e.G. Medical terminologies and high quality data to
support information sharing across wide networks
2. Ethical, legal and technical issues linked to accuracy,
security confidentiality and access rights are set to
increase as national EMR systems come online.
3. Common record architectures, structures
4. Clinical information standards and communications
protocols
5. Security and confidentiality of information
6. Patient data quality; data sets, data dictionaries

18. The required length of storage of an individual
electronic health record will depend on national and
state regulations, which are subject to change over
time. While it is currently unknown precisely how long
EHRs will be preserved, it is certain that length of time
will exceed the average shelf-life of paper records.