- An electronic medical record is any medical record that is kept in electronic format. They contain the same information as traditional paper medical records (e.g., patient name, condition, medicine prescribed), but the data is not written out longhand. Instead, it is entered into some type of electronic device such as a computer or PDA; the data can be retrieved by these devices later when needed.
- Electronic medical records most commonly are created on computers. The computer is set up with some type of record software, and a technician enters data into fields in the software to save it into the system. Most types of medical record software have the ability to search for particular data such as a patient's last name or insurance number. This lets the data be retrieved very quickly. Electronic records also can be created by sophisticated medical devices, such as when a heart monitor sends data to a server during a stress test. Due to advances in technology, they even can be created through applications on cellular phones.
- As with traditional medical records, technicians still need to verify that the information contained in electronic medical records is accurate. Electronic medical records must be unaltered and be authenticated in order for them to be accepted for use.
- Electronic medical records greatly reduce the amount of space needed for record storage. They also decrease the amount of time that must be spent physically retrieving files. They can be transmitted over long distances in a matter of seconds, and they can be more legible than handwritten records. Lastly, electronic records speed up billing and inquiry processes, which means the hospital is able to serve more people and provide better service.
- Electronic records are prone to data-entry error. They also are sensitive to data corruption; if an electronic record is lost and there is no paper record, there may be no way to retrieve the data. Electronic record keeping also means that those who create and use the records must be comfortable with the related technology. Costs may rise for the hospital due to training requirements, the purchase of necessary equipment and technology support.
