Using the Healthcare Record

Access to health information is changing the way doctors care for patients. Doctors now have access to a patient’s medical history, surgeries, allergies to medicines, and recent doctor’s visits all at the press of a button. This integration of technology and health information from a variety of sources is known as an electronic health record. Healthcare team members must understand how to use electronic record software in the ambulatory or inpatient setting. This includes inputting data into the electronic health record using the facility’s EHR software, updating the health record appropriately, and complying with all medical, legal, accreditation, and regulatory requirements associated with electronic health records. Some staff must also obtain information from the electronic health record to complete insurance claim information as well as billing, collections, and reimbursement tasks for the medical facility.