What Does an Electronic Health Record Contain?

The use of electronic health records (EHR) is becoming more prevalent across the healthcare sector. In 2017, 94% of hospitals were using clinical data from their EHR system to inform clinical practice.   

But as a patient or a provider of healthcare services, you might be wondering, what does an electronic health record contain? It’s important to be fully informed about how your personal data is being used, so read on to find out more about electronic records and the information they contain. 

What Is an Electronic Health Record?

The first question to answer is, what is an EHR? EHR systems are a vital part of health IT and a way to collate healthcare information to make it available across multiple providers. This enables the more efficient provision of healthcare and better decision-making.  

What Does an Electronic Health Record Contain? 

An electronic health record is a software system that contains a digital version of the patient’s paper health records. The provider maintains this over time and thus provides a real-time, patient-centered source of information.

Some of the information which an electronic health record might contain includes:

• Medical history
• Vital signs
• Medications 
• Diagnoses and treatment plans
• Immunization dates
• Allergies
• Radiology images
• Laboratory and test results
• Administrative and billing data
• Patient demographics   

This information is created and managed by authorized providers in digital format. It can be shared across healthcare providers such as laboratories, specialists, pharmacies, emergency facilities, medical imaging facilities, and clinics at schools and workplaces. 

The Benefits of Electronic Health Records 

The most obvious benefit of electronic health records is that information is shared between providers, with clear benefits to patients and clinicians alike. For clinicians, it can improve the efficiency of workflow, by making all the required information available in one place.

For patients, there is a reduction in duplicated tests, fewer delays in treatment, and a reduced chance of medication errors. This means that treatment is likely to be delivered more safely and quickly.  

The EHR is more than just a computerized patient chart though. EHR systems can provide access to evidence-based tools that can help clinicians make decisions about patient care. This has the potential to streamline care and improve patient outcomes. 

EHR systems organize and interpret data and ensure that clinicians can react to it appropriately. Clinical reminder alerts can be set up and experts can connect together to support health-care decision making.

Many hospitals also use EHR systems to analyze data that has been aggregated across multiple healthcare settings. This means the total health of the patient can be the focus, with data shared across all the organizations that compile it. 

Understanding the Electronic Health Record

Now you know the answer to the question, what does an electronic health record contain, so you will have a better understanding of how your personal data is being collected and managed. 

The benefits of EHR systems are clear for both patients and providers alike. They provide patient-centered care, supported by up-to-date and relevant clinical information.

Be sure to have a look at the other relevant articles about healthcare on this site which can benefit you and your business.