A medical record is the sum total of a patient’s life and health history.  It is an organized documentation of health complaints, diagnostic tests and results, treatments, and outcomes of those treatments. In addition to clinical information, the record should easily allow the healthcare provider to confirm the patient’s identity, substantiate diagnosis and associated treatments, and include the outcomes resulting from these treatment.  Previous and current health conditions and their treatments are documented by trained medical providers participating in the patient’s care.

Documentation is expected to be completed in a specified amount of time and include information that supports the principle diagnosis, recommended treatment(s), and the ensuing outcome).  The medical record is the “who, what, where, when, and how of patient care during hospitalization.  It is the knowledge concerning the patient and his care.”  The prevailing concept is that while patients can forget their health history or fail to recall significant details, the written documentation provides these important pieces of information since it does not forget.

Documentation of treatments completed on people dates back to as early as 25,000 B.C. Murals have been discovered in Stone Age caves. Illustrations showing amputations of fingers and trephining, the practice of removing circular sections from a bone, especially the skull, were discovered in Spanish Paleolithic caves. As civilization developed, so also did the documentation of patient care.   While records were created in various formats and styles over the centuries, they were nonetheless considered important elements of posterity to be preserved and ultimately shared with future generations.

There are many variations and definitions of electronic medical records (EMRs).  “EMR” is considered to be the oldest term used to describe an enterprise-wide electronic patient record system. An “EHR” or electronic health record, is probably a more accurate description of a patient’s health care provided throughout the medical system. According to HHS (Health and Human Services), “an electronic health record is a digital collection of a patient’s medical history and could include items like:

•  diagnosed medical conditions,
• prescribed medications,
• vital signs,
• immunizations,
• lab results, and
• personal characteristics like age and weight.

One of the main features of an EHR is that the information will flow automatically between the different components of the health system, following the patient wherever treated within the organization. Interoperability is a critical component for any EHR system and can only be achieved with the creation of standard formats for collecting and transmitting data.

An EHR is comprised of patient information collected over an extended period of time that is made available to healthcare providers. In its complete state, an EHR includes all patient encounters to the hospital, clinics, and other healthcare providers.  EMRs are a key component of an electronic health record system.

Another component of an EHR system is the personal health record (PHR).  A PHR, an electronic version of a patient’s health record, is intended for patient use.  These types of records do not necessarily communicate with a healthcare provider’s electronic healthcare system. Information associated with this type of record includes self-care and disease management documented by the  patient,  care  plan  and  medication  schedules  obtained  from  the  medical record, reminder notices and alerts, and available options for disease management programs to address chronic illnesses.

Four elements of an EHR

There are four elements associated with an EHR system.

2. The first one is the electronic collection of information on a patient’s health or treatment history that spans an extensive time frame.
3. The second element is the protection of patient or population-based health information by limiting access to authorized users.
4. Thirdly, the system must have the ability to extract data that can be used for decision support purposes. This component should support patient care quality, safety, and efficacy.
5. Finally, the EHR system should provide the means to facilitate improved processes in healthcare delivery.

Modified from Mila Carlson, PhD RN CLNC, CNLCP, Adoption Rates and Barriers to Implementation of Electronic Health Records in Physician Office Practices In Northwestern Illinois, Dissertation Presented to the Faculty of the School of Health and Public Administration, Warren National University

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