| Electronic Medical Records are going to be needed | | | | Management (EM) rules. This allows physicians to |
| in the future. It is important to learn the functions | | | | bill payers at the highest possible rate for the |
| of EMR and how it fits into an office work flow. | | | | services performed. |
| 1. Patient Charting | | | | 4. Document/ Image Management |
| Patient visit information is put into templates or | | | | It is important for offices to manage the |
| forms; to contain information such as vitals, | | | | enormous flow of paper entering their office. |
| complaints, medical histories, review of systems, | | | | Offices are constantly flooded with patient intake |
| physical exams, etc. Most EMR systems have pick | | | | forms, referring physician letters, lab reports, and |
| lists, drop-down boxes, handwriting recognition, or | | | | faxes. EMRs allow doctors to access these |
| voice recognition to accomplish patient charting. | | | | documents on a intuitive user interface. EMRs |
| 2. Order Communication Systems | | | | provide physicians a way to manage images such |
| This is often referred to as a Computerized | | | | as x-rays, MRIs, and ultrasounds. |
| Physician Order Entry (CPOE). This allows the | | | | 5. Patient Portal |
| Electronic Medical Records system to | | | | Personal health records allow patients to access |
| communicate information with external systems | | | | their health record from any computer with a |
| such as laboratories, imaging centers, hospitals, | | | | secure internet connection. These programs |
| and pharmacies via Health Level 7 Interfaces. This | | | | include features such as appointment scheduling, |
| allows providers to send out lab requests, imaging | | | | refill requests, electronic intake forms, record |
| requests, prescriptions, submit visit charges, and | | | | access, outcome assessments and patient |
| diagnosis codes to the office/billing system. | | | | education. The patient can also grant other |
| 3. Clinical Decision-Making Support Systems | | | | providers access to this information which allows |
| Alerts, reminders, and recommendations are built | | | | provider-to-provider communication. |
| into the system allowing automatic clinical decision | | | | 6. Statistics and Reporting |
| making with information in the database. It also | | | | Providers can create reports from databases for |
| helps doctors with coding and diagnosis. Many EMR | | | | statistical purposes. This becomes especially useful |
| systems provide physicians with a recommended | | | | in the case of drug recalls, health maintenance |
| CPT code based off of Evaluation and | | | | reminders and disease management. |