Electronic medical record is also called computerized medical record system or computer-based medical record. It is a digital medical record saved, managed, transmitted and copied by electronic equipment (computers, health cards, etc.). ) instead of handwritten paper medical records.
Its content includes all the information of paper medical records. The National Institute of Medicine defines EMR as an electronic medical record based on a specific system, which provides users with the ability to access complete and accurate data, warnings, tips and clinical decision support systems. ?
Electronic medical record is a digital patient medical record saved, managed, transmitted and copied by electronic equipment, replacing handwritten paper medical records. Electronic medical record has the characteristics of initiative, completeness and correctness, knowledge relevance and timeliness. It is a digital medical service record for medical institutions to guide and intervene outpatient and inpatient patients (or health care objects).
Electronic medical record refers to the information about personal lifelong health status and medical care managed by electronic means. It can be used as the main information source to replace paper medical records in medical treatment and meet all the needs of diagnosis, treatment, law and management.
In terms of information content, the current view is that EHR includes not only personal medical records, that is, all medical information of outpatient and hospitalization, but also personal health records, such as immunization, physical examination and health status.
Some people think that electronic medical records should include health information recorded by individuals in addition to information generated by professional medical and health institutions. From the perspective of time span, electronic medical records should cover the whole process of individuals from birth to death.