Electronic medical records (EMR) are electronic systems used to record, store, and retrieve medical information. The different types of EMR data include patient data, appointment data, laboratory tests and results, and insurance information. This information is stored electronically so that physicians can access it easily during an appointment or laboratory test.
The patient information part of EMR data includes details about the patient that may be relevant for the physician. For example, the patient’s age, sex, and marital status are recorded, just like on a paper medical chart. An EMR system may also keep track of medical history such as pre-existing conditions and prescriptions or supplements the patient is taking or has taken in the past. Physicians will also record a patient’s family medical history in an EMR system.
Another type of EMR data is the information about a specific appointment a patient has with a physician. The physician will record the complaint, or the reason the patient came into the office. Physicians may also measure blood pressure, and listen to a patient’s heartbeat or breathing. This data also is recorded in the EMR system.
During the appointment, a physician may make a diagnosis based on the patient’s complaint and symptoms. This is another type of EMR data that is added to the patient’s record. The physician will also record a treatment plan for the patient, and may return to the chart later to include the outcome of the treatment plan. Some EMR systems have programs that will remind a physician to follow up with a patient after a certain period of time.
Results from laboratory tests and radiology are another type of EMR data. An EMR system may send information about a patient’s condition to the radiologist along with his or her X-ray. Laboratory tests ordered by a physician will be recorded in the EMR system, and the results will be sent to the physician for analysis. Some EMR systems also have built-in reminders to warn physicians and patients about tests that need to be done on a regular basis.
After a patient is treated by a physician, the EMR system may record and keep track of that patient’s insurance information to make the billing process smoother. The diagnosis given by the physician is another type of EMR data. Each diagnosis is assigned a billing code that tells the insurance company what the condition is. EMR systems may also keep track of whether or not a patient’s bill has been paid.
