The electronic medical record system (EMR) is an electronic record of health information about an individual created, collected, managed, and negotiated by doctors and authorized staff in a healthcare organization. EMM also has the potential to provide physicians, clinical practice, and healthcare organizations. This system facilitates workflow and improves the quality of patient care and patient safety.
EMR is a document that contains information on the treatment of digital versions of patients produced and recorded by medical officers who treat and manage patients.
It is generally known that the use of Electronic Medical Records (EMRs) in the hospitals of the Ministry of Health Malaysia has had a positive impact in the patient care process
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Each EMR shall comply with all State and Federal laws and regulations. In addition, all hospital-hospital records and hospital-based clinics must comply with the requirements of the applicable Medical Staff Regulations and Regulations for timely information and settlement information. All documentation and entries in the Medical Record whether paper or electronic must be identified with the full name of the patient and the unique medical record number for each patient.This is to avoid mixing information from various patients. Each page of two-page or multi-page form must be marked with the full name of the patient and the unique medical record number since a page can be photographed, faxed or inspired and separated from the whole. And all Medical Records entries should be made as soon as possible after the registration of the patient is available or after the inspection is made. Admission can not be made Medical Record before service is given to the patient.
There are many benefits to implementing the EMR system, whether tangible or intangible. One benefit can be the ability to easily share information between different locations. Through ENR, treating physicians can get immediate results of clinical trials, diagnosis and treatment recommendations to be given. Hence waiting time for patients can also be reduced especially during outpatient
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Here are some of the obstacles and weaknesses identified in the use of EMR in the patient care and management process is management change. Change of mind or thinking is the challenge required to ensure the culture of using a full computer system for dealing with medical records documentation from paper usage as medical personnel are more comfortable using paper and writing manually. Information technology literacy is also required for the use of EMR because there are sometimes technical problems in computer software and hardware that make medical personnel less easily using EMR for maintenance information records due to the