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Click here for more sample CPC practice exam questions and answers with full rationale

What Is Electronic Medical Record?

An electronic medical record, or EMR, is typically a digital legal medical record created in an establishment that delivers health care, such as a hospital, a clinic, or a medical office. Electronic medical records are likely to be a part of local stand-alone health information systems that permit storage, recovery and management of documents.

Documentations on paper form need a considerable room for storage space in contrast with digital records. In the United States, most states require tangible records be retained for a minimum period of seven years. The costs of media for storage, such as paper and film, information per unit is dramatically different from that of media storage for electronic files. When paper documents are stored in various locations, gathering them to a single place for evaluation by health care personnel is time-consuming and complex, while the procedure can be simplified with digital records.

This is especially true in the case of individual-centered records and documents, which are impractical to retain if not digital, thus it is difficult to be centralized or federated. When paper-based records are needed in multiple locations, copying, faxing and transporting expenditures are considerably higher in comparison with duplication and transfer of electronic records.

A research approximates electronic medical records increase efficiency by about six percent per year, and the cost per month of electronic medical records is offset by the cost of only a few unneeded examinations or admissions.

Handwritten paper medical records can be voided due to poor legibility of the glyphs and symbols written by hand, which can contribute also to medical errors. Pre-printed forms, the standardization of used abbreviations, and standards for penmanship were pushed upon to further improve reliability of paper medical records. electronic medical records help with these standardizations. Digitization of forms facilitates the collation of data for clinical studies.

On the other hand, electronic medical records can be continuously updated. The capability of exchanging records and documents between different electronic medical records systems would make coordination of health care delivery in non-affiliated health care facilities possible. Furthermore, data from electronic medical records can be used anonymously for statistical reporting in issues quality development and improvement, resource management and public health surveillance for communicable disease.

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