The medical records arrived and it is time to evaluate what type of files you actually received. Electronic medical records or EMRs describe anything from paper records being scanned into a PDF format to an actual EMR. The records can also be a combination of scanned records and computer generated EMR information.
True EMRs are created by entering medical information and data into a computer software program. Healthcare organizations make a significant investment into implementation of a computerized program. In addition to the purchase price of the software, the additional costs of training, project management, implementation, and hardware impact the overall decision to move forward with an enterprise-wide application.
Benefits of EMRs
Once implemented, the EMR is expected to generate medical records that are more efficient for healthcare providers. Benefits include increased ability to
- read the records
- utilize them for prescribing care, and
- provide continuity of care.
EMRs also provide a more detailed record for legal nurse consultants to review and evaluate. Regardless of the software application that is purchased and implemented, there are major features common to all of them.
Experienced staff members from each department are designated to participate in the implementation process. Their expertise is used to design screens that accommodate work flow and data capture unique to the organization’s needs.
The end users become familiar with the screens they see on a regular basis. What is unseen, is that the hard copy reports do not mimic the screens.
Legal nurse consultants exclaim, when they see the first set of printed EMR generated reports, “The records look nothing like the screens!”
Evaluating what you have when the medical records arrived is an important first step in assisting your attorney-client. Printed EMR records usually have a system-generated page number. Missing pages can be easily identified and requested from the attorney’s office.
Common Issues with EMRs
Two common issues with printed EMRs are
- the duplication of the same information several times in the record and
- the lack of page breaks between departmental records.
The nursing notes may end at the middle of a page and the respiratory therapy section begins at that point. You may need to make a photocopy of the page that includes notes from two departments. This is manageable for a few pages but may be unwieldy if you do not have a copier or there are many such split pages. Or, deepending on the case and the type of report required, this may not be an issue.
A project that involves organizing these records by department requires a more in-depth approach. When the case requires manipulation or organization of the records received, always maintain the original file and create a copy.
One thought about duplicate records: when the records are from multiple providers, do not readily discard the items that you identify as duplicates. Many times the same CT scan report, MRI report or consultation may appear in each of the provider’s records. The case may rest on the fact that one of those providers did or did not receive the document in question. Noting that the report is included can be an important factor in deciding whether the case has merit.
Mila Carlson, PhD, MSHSA, RN, CLNC, CNLCP, LNCP-C prepared this guest blog post. Learn more about medical records organizing and processing by investing in our new digital learning opportunity The Medical Records Arrived: Deciphering Paper or Electronic Records. Join Pat Iyer MSN RN LNCC and Mila Carlson, PhD, MSHSA, RN, CLNC, CNLCP, LNCP-C as we explore how the use of electronic records for case review will increase as more facilities move toward utilizing EMR software. Becoming more familiar with these types of records will allow you to improve record review in an expeditious manner.
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