The electronic medical record (EMR) is a computerized record that keeps patients’ health information gathered, managed, and accessed by approved clinicians, staff, and other medical consultants within the healthcare organization. The EMR is significant in ensuring the quality of patient care is improved and facilitating workflow. An electronic health record (HER) is an electronic paper chart that operates in real-time and holds patient-centered records made available whenever authorized medical personnel requires the information (Giddens, 2019). The EHR is different from the EMR in that it does contain the medical history of the patients. Furthermore, the EHR system keeps information beyond the clinical setup to a broader view, including patient care (Giddens, 2019). The EHR forms the essential part of the clinical system as it includes the medical history of the patients, immunization dates, diagnoses, allergies, laboratory tests and results, treatment plans, and radiology images.
The safety of EMR and EHR continues to increase as Health IT specialists keep on incorporating various programs such as the clinical decision support system (CDSS), Health information exchange (HIE), and computerized physician order entry (CPOE). These features are significant in ensuring that medical errors are reduced while increasing the safety of the patients (Zerwekh & Garneau, 2020). The systems keep records such as medical history and laboratory data that help clinicians provide an accurate diagnosis. This has eliminated the paper records, which accessing may be difficult. The systems have focused on ensuring quality care delivery and maintaining the patients’ records’ integrity and safety (Zerwekh & Garneau, 2020). The systems have unforeseen complications that occur whenever they are misused. The consequences are very challenging as they may result in severe treatment and diagnosis mistakes. The errors become significant when wrong medications, treatment delays, and overdoses occur. These errors affect all groups within the population, with pediatric and older people being susceptible to serious problems.
Giddens, J. (2019). Concepts for nursing practice (3rd ed.). Elsevier Health Sciences.
Zerwekh, J., & Garneau, A. (2020). Nursing today (10th ed.). Mosby.