From documents on paper to electronic medical records
Lino Carrajo1, Angel Penas, Rubén Melcón
1R&D&I, Information Technology Department, CHU Juan Canalejo, A Coruña, Spain.
Abstract:
This paper describes the creation process of an electronic medical records (EMR) application in the Juan Canalejo University Hospital Complex (CHUJC). From the knowledge acquired through the observation of the traditional processes of managing the Patients medical records on paper a tool was developed which in principle was thought of to classify electronic documents associated to a patient and to which different functions of medical work have been subsequently added: visualizing clinical documents of patients, creation of new documents and following the development of patients.
Related Concept Videos
01:30Methods of Documentation VII: EMR
01:26Methods of Documentation II: POMR
01:18Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
01:18Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
01:11Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
01:19Purpose of Health Records II