Comparison of Paper Medical Records and Electronic Health Records

- Comparison of Paper Medical Records and Electronic Health Records (continued) EHR Method Process Perform physical examination Order tests or prescriptions Provide health education literature to patient Paper-Based Method 0 Physician reviews the forms the patient and medical assistant have completed. . Physician documents encounter during and after the appointment. 0 Physician may dictate findings, which are trane scribed by a medical assistant or a transcrip- tion service, then added to the patient's paper chart. . Write a prescription by hand and give to pa- tient to take to pharmacy. Call pharmacy with the prescription request. . Write an order for lab test or X-rays by hand and give to patient to take to the laboratory or radiology facility of choice. - Patient must remember to take the written or- der with him or herat time of appointment. - Locate the appropriate brochures to give to patient. Physician accesses the patient’s EHR in the examination room. Physician documents findings and recommen- dations while interviewing and examining the patient. Documentation is complete at the end of the encounter. Enter prescription request into the EHR, elec- tronically sending it to the patient's pharmacy and recording it in the patient's chart at the same time. Generate the order for lab tests or X»rays elec- tronically, often with the ability to send the order to the radiology facility or laboratory of the patient's choice. When patient arrives for the lab test or X-ray, the facility accesses the order in the EHR and performs the procedure. Software prints a visit summary with appropri— ate health education information, based on diagnoses and tests selected by the physician.