is an electronic medical record simply a neatly typed version of the traditional medical record


Most systems have taken the data categories of the paper systems and organized the computerized version around the categories. Physician’s orders, progress notes, nurse’s notes, radiology, laboratory reports and medication administration records are the computer “folders.” In a paper system you simply flip to the section of the chart that contains what you want and read the information. One of the biggest challenges in developing EHR is ready access to information.

As one doctor recently testified in a case of mine, “I never can find the consultants reports in the computer but they’re working on it.” In my experience, doctors frequently testify that they do not review nurses’ notes. But now with the EMR, they can’t even find them. That testimony concerned the issue of communication between the nurse and the doctor. Essentially, what we have seen is that much of the medical chart is not even available to some health care providers.

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