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EMR and Medical Documentation

Electronic medical records (EMRs) are a digital version of the paper charts in the doctor’s office. An EMR contains the medical history, medicine, vaccination dates, test results, allergy, and diagnosis history of patients within one health organization. On the contrary, Electronic Health Records (EHRs) is a digital record that contains patients’ medical information from various clinicians and provides an all-inclusive, long-term view of a patient’s wellbeing. EHR ensures the efficient coordination of patients’ medical care by ensuring the patients’ medical information accessibility to various healthcare facilities. This paper discusses why some medical offices do not implement electronic health records and the pros and cons of EMR with examples in my current or future role in medical billing.

Various reasons lead to medical offices not implementing electronic health records. The constraints facing EHR include high cost, technical confines, regulation restrictions, and administrative restraints. The EHR merchandise is costly and requires a major investment in acquiring well-trained doctors and advanced systems to store the health information. The EHRs have a high monetary risk due to more input in purchasing and upgrading software systems and the rampant computer malfunctions which lead to billing errors in the computer software. Many doctors consider EHRs as time-consuming and impractical to use in the recording of a patient’s medical history (Gill & Borycki, 2017).

The advantages of using electronic medical records include HIPAA compliance and easy accessibility of the patients’ medical information. The EMR software ensures strict conformity to the health regulations and accountability through software upgrades. Furthermore, the doctor can access the medical records outside the healthcare facilities in case of a house call or an emergency. Secondly, the efficient and smooth communication between the clinicians and their staff or their patients thus ensuring better workflow and upholding the patient-doctor privilege as patient information is shared discreetly (Gill & Borycki, 2017).

In addition, EMR increases staff productivity by a smooth workflow that lowers the high cost of having multiple systems. The EMR streamlines the coding and billing of the medical coverage in the insurance forms provided. Fourthly, the provision of better and effective medical care due to the easy accessibility of the medical history necessary for making a diagnosis and treatment plans, the EMR ensures that the service provided by the staff in the billing of patients is accurate and to their satisfaction. Lastly, the decrease in errors related to misinterpreting handwriting or transcription. As observed in my current role in medical billing, the EMR speeds up the process and ensures minimal billing errors (Heart et al., 2017).

The disadvantages of using electronic medical records include the high amount of time spent in EMR training of the medical staff. Secondly, the loss of patients’ medical history due to technical errors or malicious hacking of the EMR software hence crippling the treatment plans. Thirdly, the complication in the workflow leads to more work for the medical staff in organizing and sharing the patients’ medical records to other healthcare organizations lacking the EMR software. In medical billing, technical errors may lead to overbilling of patients with relation to the service provided by the medical staff (Heart et al., 2017).


Gill, R., & Borycki, E. M. (2017). The use of case studies in systems implementations within health care settings: A scoping review. Building Capacity for Health Informatics in the Future, 161499742X, 9781614997429

Heart, T., Ben-Assuli, O., & Shabtai, I. (2017). A review of PHR, EMR and EHR integration: A more personalized healthcare and public health policy. Health Policy and Technology, 6(1), 20-25.


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