Health Record Overview
Patient record documentation has long been the responsibility of the provider, and it is still completed on paper by the majority of the practices in the United States. Hospitals and forward-thinking ambulatory care providers have been adapting electronic charting systems, known as electronic health record or electronic medical record software. The electronification of the patient records is only the first step. EMRs can bring additional decision support and patient safety measures to the provider's attention. Lab results and images can be exchanged electronically, and prescriptions can be sent automatically to the appropriate pharmacy.