What Information Is Stored in EHR and EMR Software?

April 15, 2023

EMR and EHR software help improve patient safety, care, and engagement. A plastic surgery EHR can automate workflows and enhance documentation accuracy in your practice. Here is more about EMR and EHR software and what information is stored in them.

What Is EMR?

EMR stands for electronic medical records. A single provider maintains these electronic medical records. With EMR, you can track your patient's medical history in one place. This software can be suitable if you have a small practice and see a few patients each day. EMR lacks interoperability or scalability due to the limited features it has. You can use EMR to store diagnosis information and treatment plans. 

What Is EHR?

EHR stands for electronic health records. Like EMR, EHR is a digital version of a patient's paper charts. With EHR, multiple providers can access and maintain electronic health records. Electronic health record software allows authorized providers to access and edit a patient's medical history, diagnosis, treatment plan, and more, regardless of which provider entered the original information. The interoperability of EHRs allows patient data to be shared between pharmacies, specialists, laboratories, and imaging centers.

Types of Information Stored in Plastic Surgery EHR & EMR

Plastic surgery EHR is just one example of EHR software that can store sufficient information to boost practice efficiency and provider communication. Here are some specific types of information you can store within your electronic health and medical records:

Patient Demographics

Patient demographic information includes the patient's name, address, phone number, gender, date of birth, and emergency contact information. By storing patient demographics in EHR and EMR software systems, your practice can reduce the costs of printing and storing physical paperwork.

Medical History

A patient's medical history includes details about a patient's past and current medical conditions. This can include current or previous allergies, medications, surgeries, hospitalizations, and family medical history. Various providers can access the patient's past lab results, diagnoses, and current prescriptions through EHR software to offer better treatment and care. 

Preoperative Evaluation

In plastic surgery, preoperative evaluations can include data about a patient's general health and fitness for plastic surgery procedures. Providers can also add imaging studies and preoperative test results to the electronic health records system. 

Surgical Plan & Intraoperative Notes

The surgical plan includes information about the type of surgery, surgical method, doctors involved, and expected outcomes. Intraoperative notes can refer to the type of anesthesia used, the duration of the plastic surgery, and any complications incurred. Keeping these notes in an EHR system allows other providers, like authorized imaging centers or labs, to access the information and create accurate post-op reports.

Postoperative Care & Progress Notes

Plastic surgery providers can store postoperative care information within EHR software. This can include information about wound care, pain management, and follow-up appointments. Authorized pharmacists can access this information through EHR to make informed decisions about post-op medications. Progress notes, details taken during hospitalization and office visits, can also be stored in EHR for easy access. These notes can also include digital images of the patient's appearance before and after their plastic surgery procedure. 

Billing Information

Plastic surgery providers can keep their billing information organized in EHR software. This system stores information about when claims were billed, insurance companies and policies, patient payment details, and when payments were received. EHR software can also manage denied claims and the entire revenue cycle to help you track your payments.

Must-have EHR & EMR Features

EMR and EHR software can have varied technology features. Here are some of the must-have features for your electronic health records software:

Patient Portal

With an easily-accessible portal, patients can check their medical records and billing information and access educational materials. This online portal lets patients communicate directly with their healthcare providers about health concerns or upcoming procedures.

Photo Management

Your EHR or EMR can include photo management features to help you store and manage before and after photos, X-rays, CT scans, and MRI scans. This feature can also allow you to digitally draw on or markup your images.

Reporting & Analytics

This feature assists you and your administrative staff in generating reports and analyzing data about your clinic. Reporting and analytics features can help track patient outcomes, practice revenue, and surgical volume. 

E-prescription

The e-prescription feature can allow patients to request prescription refills online. When EHR systems incorporate this feature, other providers can review the current medications a patient is taking to prevent potentially dangerous drug interactions.

Find a Reliable Plastic Surgery EHR

Consider investing in a reliable plastic surgery EHR or EMR that's easy to use and customize. These cloud-based systems help protect patient information and billing data and reduce paper waste and storage. A reliable EHR has distributed access control to grant system access to authorized users only. With EHR, your plastic surgery practice can experience more accurate billing, coding, and documentation processes.

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Emiy Watson

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