NOOTAN COLLEGE OF NURSING,
VISNAGAR
SUBJECT: - NURSING MANAGEMENT
TOPIC: - ELECTRONIC MEDICAL RECORDS
SUBMITTED TO: - SUBMITTED BY: -
MS. BEULA S.S Ms. TANJIM MANSURI
PROFESSOR S.Y.M.sc NURSING
HOD OF CHN NCN, VISNAGAR
NCN, VISNAGAR
INTRODUCTION
Patient record system is the digital version of the clinical
information regarding a patient.it involves
ollecting,storing,manipulating and using the available clinical
information in delivering care to the patient.
Patient record system includes:
1. Electronic medical record(EMR)
2. Electronic health record(EHR)
1. ELECTRONIC MEDICAL RECORD (EMR):
Definition:
The EMR is a medical in digital format created in hospitals.this
facilitates access to patient’s data by nurses at any allergy
interactions,clinical notes and laboratory reports.the term
electronic medical record can be expanded to include system
which keep track of other relevant medical information.
Although an EMR system has the potential for invasion to
patient’s medical privacy.
Electronic patient records is a measure to put all patients records
online so that any hospital have access to that.this would allow
sharing of information between hospitals and health authority.
Component of electronic medical record:
1. Diagnosis
2. Treatment,medicine and lab test
3. Allergies
4. physician nurse and other clinician nurse
5. floor sheet(vital signs,input and output)
6. perioperative
7. discharge summaries
Types of EMRs:
Following are different types of EMR:
Departmental EMRs its consist information Entered by a signal
hospital department.
Interdepartmental EMRs these type of the record contain
information from two or more hospital departments eg record from
the Department of Cardiology and Pharmacy etc
Hospital EMRs its consist all or most of patients information from
the particular hospital
Inter hospital EMRrs its concealed patient medical information
from two or more hospital
Electronic patient records contain all or most operation clinical
information from the particular hospital
computrized patient record this record contain patient clinical
information from the particular hospital
electronic healthcare record contain all patients health information
personal health record these record are controlled by the patient and
contain information at least partially entered by the patient
computerized medical record these type of the record I created by
the image scanning of the paper based health record
digital medical record await based record maintained by the
healthcare provider
clinical data repository and operational data store that hold and
manage clinical data collected from the health service provider
electronic client records scope is defined by the healthcare
professional for example by physiotherapist or social worker.
population health record this record contain aggregated data.
Benefits of EMR
it ensures speed and save time more time is available for patient care.
EMR is the capable of the carrying more information than transitional system.
EMR store medical transcription subjective objective assessment and plan
notes and medical goods.
improve quality of care.
Disadvantage
high cost
legal issue
technical problem
security of information is the problem
Difference between EMR and EHR
An EMR is a narrower view of the patient medical history while HER is more
comprehensive report of the pressure overall health.
An EMR is mainly used for diagnosis and treatment in a given healthcare setup
and HER is an overall report regarding patient health condition.
EMRs are not designed to be saved outside the individual practice.EHR are
designed to be shared with the different authorized health care providers and
staff in more than one organization.
Issue in electronic patient record
1. integrated system required consist use of the standard in medical terminology
and high quality data of the support information sitting across wide network
2. Ethical legal and technical issuing to accuracy security confidentiality and
access right are set up the increase in national emerge system come online
3. common records architecture structures.
4. clinical information standard and communication protocol security and
confidentiality of information patient data quality data set data disctionaries.
BIBLIOGRAPHY
1. I. Climent, “MANAGEMMENT OF NURSING SERVICES AND
EDUCATION”. Second edition, Reed Elsevier India Pvt. Ltd; 2015.
2. Basvanthappa B.T. “ NURSING ADMINISTRATION”. Seond
edition, Jaypee Brothers Medical Publishers (P) Ltd; 2019.
3. Deepak K., Sarath Chandran. C. & Mithun Kumar. B.P. “ NURSING
MANAGEMENT”. Second edition, EMMESS Publication; 2019.
4. Principles and practice of NURSING Management
Administration.JOGINDRA VATI. Second edition,Jaypee Brothers
Medical Publishers (P) Ltd; 2020.
5. https://www.slideshare.net.patient record system(electronic medical
records).pptx
