"An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format."
This is the management of patient medical records and other healthcare-related documents.
Medical record organization: This topic covers the basic principles of organizing medical records to ensure easy access and retrieval of patient information.
Record retention and disposal: This involves creating policies and procedures for the retention and disposal of medical records in compliance with regulatory requirements.
Record security and confidentiality: This covers the principles of securing and maintaining the confidentiality of medical records to protect the privacy of patients.
Electronic health record (EHR) systems: This covers the use of electronic health record systems to manage medical records and patient information.
Coding and indexing systems: This topic covers the principles of coding and indexing medical records to ensure accurate and efficient data retrieval.
Recordkeeping regulations and compliance: This covers the various regulations and compliance requirements related to medical records management, including HIPAA, HITECH, and other state and federal laws.
Record audit and quality control: This involves monitoring the quality and accuracy of medical records through audits and other quality control measures.
Disaster recovery and business continuity: This covers creating policies and procedures for disaster recovery and business continuity planning in the event of a natural disaster or other emergency that could impact medical records.
Record governance and accountability: This topic covers the principles of record governance and accountability, including defining roles and responsibilities for record management and ensuring compliance with policies and regulations.
Health information exchange (HIE): This topic covers the exchange of patient information between healthcare providers and organizations to improve the quality and continuity of care.
Electronic Health Record Management (EHR): A type of records management that focuses on maintaining patient records digitally. It includes records of medical history, treatments, lab results, medication lists, etc.
Personal Health Record Management (PHR): A type of records management that allows patients to manage and access their own health records. This includes records of medical history, treatments, lab results, medication lists, etc.
Paper-Based Record Management: This type of records management involves physical records that are stored and archived manually in paper-based formats.
Hybrid Record Management: This type of records management incorporates both electronic and paper-based records, and seamlessly integrates them to provide easy access and retrieval.
Digital Imaging Record Management: Digital Imaging Records Management is a type of records management that creates digital copies of paper-based records and stores these records in electronic formats.
Release of Information Management: This type of records management focuses on providing access to medical records for the patient, the healthcare provider, or a third party such as an insurance company, law firm, or government agency.
Retention and Disposition Management: This type of records management focuses on the proper retention and disposal of medical records in accordance with laws and regulations.
Audit Trail Management: This type of records management involves the creation and maintenance of a detailed audit of the activities and changes made to medical records.
Security Management: Medical records contain sensitive information that needs to be kept confidential. Security management involves implementing technical safeguards to maintain confidentiality and protect medical records from unauthorized access or tampering.
Quality Management: This type of records management focuses on the quality of medical records and ensures that they are accurate, complete, and up-to-date. It involves monitoring, auditing, and reviewing medical records to ensure that they meet the required standards.
"Records are shared through network-connected, enterprise-wide information systems or other information networks and 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."
"Today, providers are using data from patient records to improve quality outcomes through their care management programs."
"EHR combines all patients' demographics into a large pool and uses this information to assist with the creation of 'new treatments or innovation in healthcare delivery.'"
"Combining multiple types of clinical data from the system's health records has helped clinicians identify and stratify chronically ill patients."
"EHR systems are designed to store data accurately and to capture the state of a patient across time."
"It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is up-to-date, accurate and legible."
"It also allows open communication between the patient and the provider."
"...providing 'privacy and security.'"
"It can reduce the risk of data replication as there is only one modifiable file."
"...decreases the risk of lost paperwork."
"...is cost efficient."
"Due to the digital information being searchable and in a single file, EMRs (electronic medical records) are more effective when extracting medical data for the examination of possible trends and long-term changes in a patient."
"Population-based studies of medical records may also be facilitated by the widespread adoption of EHRs and EMRs."