Steps for Implementing an EMR

An EMR, electronic medical record, is a file that contains a patient's information. A patient's demographics (name, age, address), medical history, allergy and medication list are among the information found in an electronic medical record. Physician offices, hospitals and nursing homes are using EMR's across the globe. They are convenient and help prevent medical errors because all health care providers have access to complete patient medical files. Converting a health care system from a hard copy medical record systems to an EMR system can be accomplished by following a few simple steps.

Instructions

Steps to Implement an EMR System

• 1

  Choose EMR software that is best suited for the medical office. Pick software that is both compatible with the office's computer system and easy for employees to use. EMR software programs can be purchased from software companies, medical supply distributors and online. Install the chosen software onto the office computer system. Test the system to ensure it is working properly prior to office use. Consult an IT or program specialist to answer questions or correct any problems that arise. Older computer systems may need to be upgraded or replaced to be compatible with EMR software.

• 2

  Once it has been installed and is working properly, teach the staff how to use the EMR program properly. Lessons on how to use the system may be given individually or to groups. Instruct employees how to log onto the system and create an EMR. Show them how to enter, change and delete information in a file. Address any staff questions or concerns. Assign user IDs and passwords to all those requiring access to a patient's medical file. Add restrictions to files if needed. Restrictions may help ensure patient privacy by limiting access to sensitive patient information. For example, the office billing staff may have restrictive access allowing them to view a patient's billing information only.

• 3

  Create an EMR for each patient using information gathered from the existing medical record

  Create an EMR file for each patient seen by the health care professional. Gather the information needed to enter into the EMR from the patient's hard copy medical record. Enter each patient's information into individual EMR files. Make sure the information is entered correctly into its proper section in the EMR to prevent errors. Proofread all EMR files to assure the information is accurate and up-to-date. Scan forms such as treatment consent forms into the patient's EMR. Save each patient's EMR every time information is entered or deleted from the file.

• 4

  Advise patients, fellow health care providers and facilities that the office has converted to an EMR system. Assign fellow health care providers user IDs, passwords and restrictions as needed. Teach those unfamiliar with the system how to access, add or change patient information in the EMR. Inform patients that their records have been converted from a hard copy chart to an electronic medical record and answer any questions involving the EMR. Explain how simple the EMR system is and how it is beneficial to patients because it allows multiple health care providers to access the file and review the information, which may decrease the number of medical errors that may occur when health care professionals are ill informed.

• 5

  Keep records updated and make changes when necessary. Each time a patient comes into the office ask them if any of their information, such as address or insurance company, has changed since their last visit. If something has changed, enter the correct information into the patient's EMR and save the file. Update patient EMRs any time diagnostic testing is ordered. Add test results and any new diagnosis to the electronic medical record as needed. Alert health care providers if changes like test results are entered into a patient's EMR.