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Overview Of An Electronic Medical Record (EMR)

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An electronic medical record (EMR) is a term used to describe a system that involves integrated dictation, print files, transcription, and scanned documents. An electronic health record (EHR) is a term to describe a system that is used by clinicians at the point of care as well as aid in clinical decision support. The National Alliance for Health Information Technology, NAHIT, offers the following definitions: EMR- “an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization” (Sayles, 2013); EHR- “an electronic record of health-related information on an individual that conforms to the nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization” (Sayles, 2013). …show more content…

Source systems include administrative, financial, ancillary, and departmental sources. This is where the EHR gets all of its information. There are 5 main components that make up the core applications of an EHR: results management, clinical documentation, closed-loop medication management, clinical decision support, and analytics and reporting. These are the functions that are required for eligibility for the meaningful use incentive program developed by CMS to increase EHR adoption. Results management converts diagnostic study results to be readable in a report format and allows the data to be processed. Clinical documentation applications provide the framework for point-of-care

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