Health Information Management and the EMR

Publisher Summary The electronic medical record (EMR) allows clinical information to be available at the point of care. One important advantage of the EMR is that it allows multiple accesses concurrently. The medical center must define its legal medical record and determine what belongs in the medical record and what doesn’t. The goal for health-care providers is ease of access to locate clinical information needed to monitor and make patient care decisions, which is not easy to achieve. Health-care delivery is complicated with many professionals serving numerous roles. There are countless pieces of data collected and recorded on a patient. The organization and layout of individual notes and the entire medical record is a challenge as well and the number of documents that make up a complicated patient's record is impressive. This chapter describes how patient information is entered into an EMR, emphasizing the fact that this is not an easy process and might take up a lot of time. Finally, it describes the role of the health management department, which includes coding, medical transcription, medical record analysis and completion monitoring, document imaging, master patient index management, release of information, HIM education and training, and documentation abstracting and audits.