Medical Records

What is a Medical Record? A record of health information developed over a period of time. It is generated by one or more encounter in any health care delivery setting.

What is Included? Patient demographics Advance Directives Living Wills Progress Notes Problem/Summary Lists Medications Vital Signs Past Medical History Immunizations Laboratory Data Radiology Reports

Paper based records are being replaced by electronic health records. Traditional paper records and current computer based records exist mainly in closed health systems/organizations.

Why Electronic? Currently, information is not shared between organizations (Doctor’s Office Visit, Specialist, Emergency Rooms, Long-Term Care Facilities and other health organizations) especially if they are not within the same hospital origination. The goal put forth by the of the Presidential Committee of Advisors in Science and Technology (PCAST) is to create a more flexible technological approach to healthcare transmitted across organizations by 2015. This would create a national electronic medical record with the capability for health data to be broken down, indexed, re-assembled, and aggregated so consumers may realize the many potential benefits of an electronic medical record.

Benefits of an Electronic Health Record The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter that supports other care-related activities directly or indirectly via interface, to include but not limited to: Ability to make evidence-based decisions. Conduct quality management/quality improvement activities. Report outcomes and make comparative data related to communities or regions.