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Electronic health record

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Definitions Edit

An electronic health record (EHR) is

an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff.”[1]
a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter — as well as supporting other care-related activities directly or indirectly via interface — including evidence-based decision support, quality management, and outcomes reporting.[2]
a collection of information about the health of an individual or the care provided, such as patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports.[3]
is a repository of information regarding the health status of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorised users. It has a standardised or commonly agreed logical information model which is independent of EHR systems. Its primary purpose is the support of continuing, efficient and quality integrated healthcare and it contains information which is retrospective, concurrent, and prospective.[4]

Overview Edit

The use of information technology (IT) to electronically collect, store, retrieve, and transfer clinical, administrative, and financial health information has great potential to help improve the quality and efficiency of health care. Historically, patient health information has been scattered across paper records kept by many different caregivers in many different locations, making it difficult for a clinician to access all of a patient's health information at the time of care. Lacking access to these critical data, a clinician may be challenged to make the most informed decisions on treatment options, potentially putting the patient's health at greater risk. The use of electronic health records can help provide this access and improve clinical decisions.

References Edit

  1. Pub. L. No. 111-5, §13400(5).
  2. American Health Information Management Association (AHIMA), Glossary of Terms (full-text).
  3. Electronic Health Records: VA and DOD Need to Support Cost and Schedule Claims, Develop Interoperability Plans, and Improve Collaboration, at 1 n.1.
  4. Security and Resilience in Governmental Clouds, at 58.

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See also Edit

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