A paper patient record is recognized by name, serial, membership,
reference or medical record number, and other identifiers that make it
easier to find in the physical filing system. It takes long time to sort
thousands of files, whenever patient or doctor requires checking
previous medical history or updating the status of record. On other
hand, an EHR provides dissimilar identifying information for each
patient, and identifiers to locate the digital record among any number
of records. Due to its digital nature, finding patient record is concern
of merely seconds.
If a paper chart is filed correctly in the medical records system, a
staff member must go to the stacks of charts, using some quick
identifier code. After matching the exact last name and first name, then
the chart is "pulled" for desired review. Sometimes, a placeholder is
inserted in stack, to make re-filing easier and for reference where the
chart is headed. In this whole manual process, there is great potential
of human mistake; any file can be lost easily due to slight negligence.
An electronic chart is never lost, out, or misfiled because it is always
exactly where it should be. An electronic record may be accessed from
any point in a healthcare facility that has access to medical records.
A paper medical record includes office or progress notes in
chronological sequence. These are sorted and searched by flipping
through pages, until the desired entry is located. Progress notes in a
traditional paper record might be produced by dictation/transcription,
free handwriting, or form completion method. An EHR keeps progress notes
and provides quick access by date of visit, provider or other
accessible search criteria and the ability to browse by diagnosis and
prescription. A full function EHR automatically creates the progress
notes, as the visit is produced.
Laboratory and radiology reports, as well as related communication, are
filed in more or less chronological order. Access to specific/desired
entries can be prolonged or slow. An EHR stores reports/information in
number of ways to provide quick access and speedy reference, such as
scanned images, direct lab results or even on-line laboratory
information. Access to common demographic and information is highly
resourceful and useable due to implementation of EHR system in any
practice.
In a paper chart system, a healthcare provider typically writes a paper
prescription for the patient to take to a pharmacy. Actually, once this
information has been adequately obtained, the paper prescription is
handed to the patient. It is then necessary for the provider to document
the process (that just took place), including the negative potential
for drug interactions and allergies, as well as the form, strength,
quantity, and directions for the prescribed drug/medicine. On other
hand, EHR with strong clinical “decision support”, offers reference
information regarding most-favorable treatment, such as treatment
guidelines or "best practice standards”. An EHR with prescription
writing capability performs the allergy and drug interaction checking,
or at least provides a quick reference for manually checking, when the
desired drug is selected. In addition, an EHR with electronic
prescribing capability can send the prescription to a designated
pharmacy directly/online/automatically.
Paper charts characteristically hold demographic and insurance
information, along with a list of medical problems, allergies and
medications. These must be readily reorganized and should stay up to
date and precise, manually. Some practices, use carbon copies of each
document for transferring data to concerned or relevant department(s)
such as billing. An EHR maintains this information, and shares any
updated information wherever it is needed. For example: when updated
insurance information is provided, that information is automatically
passed to billing so that the information is reliable and existing,
without the need for duplicate data-entry. In addition, clinical
information such as problem lists and medication lists are readily
updated without duplicate data-entry. EHR automatically updates the
patient's medication list. As a result, carrying out this concept saves
time, eliminates mistakes, keeps computerized revision and makes whole
process smooth and trouble-free.
Nortec EHR is “complete” Electronic Health Record system/solution for
practices, having full capacity to manage any kind of operational task.
Nortec’s suite consists of Electronic Medical Records (EMR), Practice
Management (PMS), Advanced Surescripts certified Electronic Prescribing,
Document Management, Revenue Cycle Management and a myriad of other
modules designed to automate ambulatory and outpatient physician
practices. Not only for its Stimulus Package of $44,000, Nortec EHR
provides friendly, easy and complete “Health Record Management”, if
implemented within any practice. Moving towards next era of Health IT,
Nortec EHR can be your best partner!