An electronic health record (EHR) is a more comprehensive report of the patient’s overall health.An electronic medical record ( EMR) is a digital version of a traditional paper chart that contains a patient’s entire medical history from one practice.This includes text messages and emails to patients. It is the most comprehensive record and serves as the organization’s complete business record across the continuum of care. The legal medical record is a combination of both a clinical medical record and a designated record set.The designated record set is defined in 45 CFR § 164.501 and is more comprehensive than a medical record because it includes the billing items and releases.A medical record, whether paper or electronic, can be thought of as the clinical aspects of patient care.Just getting started but thoroughly intimidated? Embarrassed to admit that after all these years you still don’t know what all these terms mean? Don’t be. Regardless of the term used, something that invariably arises with these presentations is a discussion about what information needs to be included in a patient’s medical record. The second part involves the nuances of an electronic health record (EHR) versus an electronic medical record (EMR). That’s only the first part of the equation. “Lions and tigers and bears, oh my!” This line from The Wizard of Oz often comes to my mind when I present on the subject of the differentiating between a medical record, a designated record set, and a legal medical record.
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