Electronic Medical Record
Definition Simplified

Electronic medical record definition simplified for the common man! There is so much confusion over the terminology, but the one thing for certain is that it will change the medical transcription landscape permanently.

But before we panic, let's get the electronic medical record definition clear in our minds - what it is and what it is not.

Let's start with the difference between EMR and EHR. EMR is not EHR. An electronic medical record is your own personal doctor's visit in digital form. Or, to put it another way, NOT on paper.

So, what's all the fuss about? Let's consider this topic closed and hit the bars! Except for one thing - the actual process of doing this is far, far more complicated. It's my personal opinion that any time insurance companies have their finger in the pie (and, trust me on this one, they do) things will, without fail, become 28 times more complicated than they need to be. That number is just an educated guess based on...well, a guess. And, if you add Medicare/Medicaid's fingers to that pie - well, what's 28 multiplied by 28? - it'll be just that much more complicated! Since I promised to simplify the subject, we'll have to give the whole topic of EMRs and insurance a wide berth.

Now, back to the electronic medical record definition. If you visit a doctor for the first time, they will get, or should get, a full medical history and physical on you. Remember, you have never visited this doctor before and he knows nothing about you, so in order to make an informed decision on how to treat you, he has to know at least a little something about what has happened - medically, speaking - in your past. Every infection treated with antibiotics, every operation, every hospitalization, every allergy, every medical condition (hypertension, diabetes, high cholesterol, cancer), all of your medications. EVERYTHING.

If he has an EMR system installed (at great expense, I might add), then that form you had to sit and fill out in the waiting room gets entered into their EMR system, creating a medical record containing your name, address, phone number, insurance information. After that, you get taken to an examining room where the nurse who takes your pulse, blood pressure, and weight will enter this in your newly-created medical record on a laptop or tablet PC, filling in the appropriate slots with your appropriate information, usually via a drop-down menu.

Then, the doctor will come in, ask about the details of your current complaint and, as you're talking, he will be entering this information into your newly-created medical record on his laptop. If he's any good, he might glance up at you every once in a while from his computer screen - let's hope so, anyway!

He prescribes any medication you might need - right on his laptop straight to the pharmacy's computer. In fact, by the year 2011, all prescriptions must be ordered electronically. He orders any lab work you might need and any imaging studies you might need and the goal eventually is that this will all be done electronically, including the results being sent back to your electronic medical record.

We're going take a look at the advantages and disadvantages of electronic medical records and how medical transcription is going to fit into the mix in the future, so stay tuned, including my humble predictions for how it's all going to play out and some of the major issues that will need to be addressed. But, for now, there's your simplified electronic medical record definition.

You, the patient, reduced to a drop-down menu.

Next, we're going to continue with Benefits of Electronic Medical Records