The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s medical history and care across time within one particular health care provider’s jurisdiction.[1] The medical record includes a variety of types of “notes” entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.
An electronic medical record (EMR) is a digital version of the traditional paper-based medical record for an individual. The EMR represents a medical record within a single facility, such as a doctor’s office or a clinic.
There are a number of different types of digitized health records that contain most of the same types of information. A personal health record (PHR), for example, is health-related documentation maintained by the individual to which it pertains. An electronic health record (EHR) is an official health record for an individual that is shared among multiple facilities and agencies. There are government incentives in many countries to standardize EHRs and ensure that every citizen has one.
An EMR contains the standard medical and clinical data gathered in one provider’s office. Electronic health records (EHRs) go beyond the data collected in the provider’s office and include a more comprehensive patient history.
An EMR is more beneficial than paper records because it allows providers to:
• Track data over time
• Identify patients who are due for preventive visits and screenings
• Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings
• Improve overall quality of care in a practice
The information stored in EMRs is not easily shared with providers outside of a practice. A patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.
The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems,etc. An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.
EHS systems are designed to store data accurately and to capture the state of a patient across time. It eliminates the need to track down a patient’s previous paper medical records and assists in ensuring data is accurate and legible. It can reduce risk of data replication as there is only one modifiable file, which means the file is more likely up to date, and decreases risk of lost paperwork. Due to the digital information being searchable and in a single file, EMR’s armore effective when extracting medical data for the examination of possible trends and long term changes in a patient. Population-based studies of medical records may also be facilitated by the widespread adoption of EHR’s and EMR’s
A personal health record, or PHR, is a health record where health data and information related to the care of a patient is maintained by the patient. This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians or billing data to support insurance claims. The intention of a PHR is to provide a complete and accurate summary of an individual’s medical history which is accessible online. The health data on a PHR might include patient-reported outcome data, lab results, data from devices such as wireless electronic weighing scales or collected passively from a smartphone.
PHRs grant patients access to a wide range of health information sources, best medical practices and health knowledge. All of an individual’s medical records are stored in one place instead of paper-based files in various doctors’ offices. Upon encountering a medical condition, a patient’s health information is only a few clicks away.
Moreover, PHRs can benefit clinicians. PHRs offer patients the opportunity to submit their data to their clinicians’ EHRs. This helps clinicians make better treatment decisions by providing more continuous data.
PHRs have the potential to help analyze an individual’s health profile and identify health threats and improvement opportunities based on an analysis of drug interaction, current best medical practices, gaps in current medical care plans, and identification of medical errors. Patient illnesses can be tracked in conjunction with healthcare providers and early interventions can be promoted upon encountering deviation of health status. PHRs also make it easier for clinicians to care for their patients by facilitating continuous communication as opposed to episodic. Eliminating communication barriers and allowing documentation flow between patients and clinicians in a timely fashion can save time consumed by face-to-face meetings and telephone communication. Improved communication can also ease the process for patients and caregivers to ask questions, to set up appointments, to request refills and referrals, and to report problems. Additionally, in the case of an emergency a PHR can quickly provide critical information to proper diagnosis or treatment.
The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.
Differences between Electronic Medical Records and Electronic Health Records
An EMR contains the standard medical and clinical data gathered in one provider’s office. Electronic health records (EHRs) go beyond the data collected in the provider’s office and include a more comprehensive patient history.
For example, EHRs are designed to contain and share information from all providers involved in a patient’s care. EHR data can be created, managed, and consulted by authorized providers and staff from across more than one health care organization.
Unlike EMRs, EHRs also allow a patient’s health record to move with them—to other health care providers, specialists, hospitals, nursing homes, and even across states.
An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.

Providers who use EHRs report tangible improvements in their ability to make better decisions with more comprehensive information. EHR adoption can give health care providers:
• Accurate and complete information about a patient’s health. This enables providers to give the best possible care, whether during a routine office visit or in a medical emergency, by providing the information they need to evaluate a patient’s current condition in the context of the patient’s health history and other treatments.
• The ability to quickly provide care. In a crisis, EHRs provide instant access to information about a patient’s medical history, allergies, and medications. This can enable providers to make decisions sooner, instead of waiting for information from test results.
• The ability to better coordinate the care they give. This is especially important if a patient has a serious or chronic medical condition, such as diabetes.
• A way to share information with patients and their family caregivers. This means patients and their families can more fully take part in decisions about their health care.

The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, although differences between the models are now being defined. The electronic health record (EHR) is an evolving concept defined as a more longitudinal collection of the electronic health information of individual patients or populations. (See reference 1.) The EMR is, in contrast, defined as the patient record created by providers for specific encounters in hospitals and ambulatory environments, and which can serve as a data source for an EHR.[3][4] It is important to note that an “EHR” is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patient’s medical records across facilities.[5] (Please note that the term “EMR” would now be used for the preceding description, and that many EMR’s now use cloud software maintenance and data storage rather than local networks.)
In contrast, a personal health record (PHR) is an electronic application for recording personal medical data that the individual patient controls and may make available to health providers.

• Tang, Paul; Ash, Joan; Bates, David; Overhage, J.; Sands, Daniel (2006). “Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption”. JAMIA 13 (2): 121–126. doi:10.1197/jamia.M2025. PMC 1447551. PMID 16357345.
• • “Computerisation of personal health records”. Health Visitor 51 (6): 227. Jun 1978. PMID 248054.
• • DRAGSTEDT, CA (1956-04-14). “Personal health log”. Journal of the American Medical Association 160 (15): 1320. doi:10.1001/jama.1956.02960500050013. PMID 13306552. (subscription required)
• • Connecting for Health. The Personal Health Working Group Final Report. July 1, 2003.
• • AHIMA e-HIM Personal Health Record Work Group (July–August 2005), “The Role of the Personal Health Record in the EHR”, Journal of AHIMA 76 (7): 64A–D, PMID 16097127, archived from the original on 20 Sep 2008
• • America’s Health Insurance Plans (13 Dec 2006). “What are Personal Health Records (PHRs)?”. Archived from the original on 5 Mar 2009.
• “MyChart”. Cleveland Clinic. Retrieved 29 March 2011.

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