Electronic Health Record And EHR

712 Words3 Pages
The electronic health record (EHR) and the legal health record (LHR) are both documents containing patient information but the goals in making the records are different. The EHR is defined as “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization” (Fahrenholz, C. G. & Russo, R., 2013b). The Office of the National Coordinator for Health Information Technology (ONC) has published a list of required items an EHR must have to satisfy the complete EHR definition. According to the ONC, the EHR must include, for both ambulatory and inpatient systems: computerized provider order entry, demographics, a problem list, a medication list, a medication allergy list, clinical decision support, transitions of care, data portability, clinical quality measures, authentication, access control and authorization, auditable events and tamper resistance, audit reports, amendments, automatic log-off, emergency access, end-user encryption, integrity, drug-drug and drug-allergy interaction checks, vital signs, body mass index and growth charts, electronic notes, drug-formulary checks, smoking status, image results, family health history, patient list creation, patient-specific education resources, electronic prescribing, clinical information reconciliation, incorporation of lab tests and values/results, immunization information, transmission to immunization registries, transmission to public health agencies-syndromic surveillance, automated measure calculation, a safety-enhanced design, a quality management system and be able to view, download and tra... ... middle of paper ... ... healthcare organization would want to use the smallest amount of information necessary to prove their case in a court of law or to an insurance company. The federal government has set standards for what must be included in the EHR but healthcare organizations must set their own standards for what they will include in their LHR. The biggest difference between the EHR and the LHR is what is being kept safe. Many of the ONC’s requirements for an EHR are not directly related to caring for patients but are related to keeping patient information safe; for example: authentication, access control and authorization, auditable events and tamper resistance, audit reports, amendments, automatic log-off, emergency access, end-user encryption, and integrity. In contrast, the information found in the LHR is meant to keep the healthcare organization safe during legal challenges.
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