Everything -- every little piece of information that regards your health, your doctor's diagnosis and treatment recommendations, your treatment choices, and how your care will be paid for at any touch point, may be recorded and stored for later retrieval through the use of electronic medical record systems.
Electronic medical record systems (EMRs) are becoming more prevalent across the US. If your doctor uses an EMR system, you will find that your entire appointment will be recorded in an electronic medical record (EMR.) Upon arrival, the fact that you are there for your appointment will be logged in. A check for any updates on your residence or contact information, plus any changes in your health insurance status will be made. Your height and weight, your temperature, blood pressure, any symptoms you describe or any that might be observed, diagnoses that are discussed or assigned, tests given to you while in the office -- everything is recorded.
Your next steps, including referrals, test orders, prescriptions, even hospitalization recommendations will be input to your electronic record. In short, a comprehensive record of your visit will be added to your larger record that already includes visits you have made to that doctor -- and others -- before. As time goes on, these records will be appended with each new visit, test, treatment, and anything else related to keeping you healthy.
The U.S. Centers for Disease Control and Prevention define a complete EMR system as one that contains four basic functions: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes.
Patients sometimes choose to kept their own records digitally through the use of a PHR (personal health record.) Using a PHR allows you to expand on your own records, from keeping a more extensive family medical history, to recording emergency medical information to keep in a purse or on a keychain thumb drive.
If you do choose to begin keeping your own medical records, you'll want to be aware of the benefits. You'll also want to be aware of the limitations and concerns as they regard to privacy and security issues.
Learn More:
- What is an EMR (Electronic Medical Record)?
- What is a PHR (Personal Health Record)?
- What is an EMR / PHR Hybrid System?
- The History of EMRs and PHRs
- The Benefits of Using Electronic Medical Records or Personal Health Records
- What Records are Kept in an EMR or PHR?
- A Lack of Standards Limit the Use of Electronic Medical Record Keeping Systems
- Limitations of the Use of Electronic Medical Records Due to Privacy and Security Concerns
