EMR Documents: Essential Reports Must-haves

Published on by Xenia Labis

Electronic Medical Records have several vital components. First, as its name indicates, the system is a digital record of information, particularly patients. So, EMR Documents help medical staff by giving them access to information necessary to take care of their patients.

In 2019, nearly 90% office-based physicians in the United States used an EMR or EHR system. On the other hand, the progress of EMRs in the Philippines has endless possibilities yet to be unlocked. So EMRs will be incredibly beneficial for patients, especially if their use spreads throughout the country!

EMR Documents that are Vital to Your System

EMR Systems can streamline Medical Billing, thus assisting your clinic with finances. However, they can also generate Medical Certificates, Prescription Orders, and Consent Forms. They’re crucial EMR Documents your system must never be without, as they provide accurate information to medical staff in a timely manner.

emr documentation

Medical Certificate

Medical Certificates can simply indicate the patient’s condition or clear them for a given action. The three most vital ones are:

  • Fit to Work
  • Advised to Rest
  • Fit to Travel

Naturally, medical practitioners provide EMR Documents to patients who need them. Of course, many Medical Certificate details overlap with existing patient records. Thus, it’s expected that an EMR can generate a Medical Certificate.

It includes crucial details on the patient, their medical complaints, and the examination. So, with the document, a doctor can clear a patient to work, rest, or travel. 

While a record of the Medical Certificate is stored in the EMR, it can be printed out as evidence of illness. And, of course, according to the doctor or physician’s diagnosis, they will provide a prescription. 

Prescription

Of course, after a healthcare provider gives a diagnosis, they must create a prescription for their patients. After all, a prescription includes “the information, personal details and instructions that a pharmacy needs” to provide. So, this can even include laboratory tests, X-rays, or other specialists. Additionally, many Prescriptions may have expiration dates. But, they’ll still be permanently recorded via the EMR.

emr documentation

So, an Electronic Medical Records System can either generate a Prescription Plan or a regular, basic prescription.

Since an EMR can automate data entry and recording, you can also generate and send prescriptions without any fuss. In addition, this EMR Document is perfect for authorizing medication refills quickly! Additionally, you can directly forward a patient’s prescription to partner pharmacies. Thus, upon arrival, all a patient has to do is pay for and pick up their medication.

Lastly, an EMR can track medications and notify you if a patient’s medication might not interact well with other medicines.

Consent Forms

Consent Forms should be signed by patients slated for a medical procedure. They should be capable of consent and fully understand the procedure and its risks. We discussed in our predictions for the future of EMRs that having Consent Forms on the system is vital. Not only does it save both paper records but also time.

However, getting patients to sign this EMR Document may take a while, which may hinder staff during emergencies. Consent may also take time, mainly due to informed consent discussions. Informed consent allows health care professionals to educate patients on a particular procedure. However, in a recent study, 40% of researchers “felt that time constraints were a barrier” when giving Informed Consent discussions.

Additionally, due to Data Privacy concerns, you have to deal with Consent Forms delicately.

documents for the electronic medical records

Final Thoughts

Electronic Medical Systems are crucial for automating medical institutions’ processes. In doing so, the systems save time and allow medical staff to focus on patient care. 

Overall, an EMR should be able to keep records and generate the appropriate documents. So, you can count on Electronic Medical Records in the Philippines to keep track of the documents found here!