patient medical records Flashcards
What is PMR?
a comprehensive compilation of a patient’s health information
What does a PMR includes
medical history
medications
treatment plans
test results
What is the importance of PMRs
- Ensure quality healthcare
- accurate up to date records
- Making informed medical decisions
- enhancing patient safety
- Improving overall care
Key components of PMR (there’s 9)
Patient demographics, medical history, medication records, treatment plans, test results, progress notes, consultation reports, vital signs and measurements, immunization records
What is a Patient Medication Record
a subset of the patient medical record, focusing mainly on their medication history
How can healthcare providers obtain medication information?
- patient interviews
- pharmacy records
- communication with other healthcare facilities
What are the advantages of EMRs?
- real time access
- improved medication reconciliation
- enhanced patient safety
What are the challenges in manual medication record keeping?
- illegible
- cannot access across hospitals
- lack of real time update
What are the differences between EMRs and EHRs?
EHR (broader view of patient health history)
- comprehensive health records
- encompasses various health data
- designed for data exchanges between different systems
- patient portals for access to comprehensive health data
- used in larger healthcare organisations, hospitals and healthcare network.
EMR
- patient’s medical records within a single healthcare facility
- focuses on medical history and treatment date
- limited interoperability, mainly within same facilities
- patient portals with limited date access
- small to medium sized clinics, private practices and specialised healthcare facilities
What are the benefits of EHRs?
- efficiency and productivity
- remote access and telemedicine
- data analytics
- interoperability
Name two innovations in medicine management.
- automated medication dispensing
- smart medication packaging
Name some challenges in EMR/EHR adoption
- resistance to change
- financial investment
- training ang education
- data migration and integration
Name 2 future trends in PMRs.
- AI driven predictive analytics for personalised treatment plans
- utilising blockchain technology to enhance data security and integrity
