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Electronic medical records and the emergency room
The Emergency Department (ED) is high paced and needs reliable, efficient access to patient medical records. When implemented successfully, a high-quality ED medical record should help better capture the process of evaluation, management, medical decision-making, and disposition of a patient. It should also facilitate better care by making relevant medical history instantly available.
An effective ED medical record assists with:
- documentation of clinically relevant aspects of the patient encounter
- incorporation of laboratory, radiologic, and allied health testing results
- legibility (avoiding "do not use" abbreviation use)
- clear communication with other providers
- coordination of follow-up care
- discharge instruction communication
Having medical records available electronically enhances the accessibility of patient information, allowing physicians and nurses to share recorded information with one another instantly.
Some electronic medical records systems allow ER staff to automatically retrieve past medical history, ER visits, and previous allergy history. There is now technology that would sound an alarm when there is a dangerous drug interaction, or if a patient has abnormal vital signs or when critical lab results available.
Do you have questions about an experience involving a misstep with medical records? We are here to help.