Electronic Health Record Analysis

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In the healthcare setting medical records systems, computerized delivery of health care, patient care, information management, medical record linkage, confidentiality, and policy making are all things that come to mind when we think of electronic health record (Terry, 2005). Along with discussing the electronic health record system, SNOMED CT and LOINC will also be discussed due to it’s importance in the medical setting when communicating with other medical professionals. Throughout this paper the electronic health record, SNOMED CT, and LOINC will be thoroughly discussed. According to Terry (2005), an electronic health record (EHR), is a systematic collection of electronic health information about an individual patient or population. EHR can be shared and managed with other health care providers and organization so that all information can be contained from all clinicians that were involved. This basically means a digital version of a patient’s paper chart. According to healthit.gov (2013), the EHR can typically:
• Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
• Allow access to …show more content…
It is also considered to be the most comprehensive, multilingual terminology in the world. According to the Giannangelo (2010), the general purpose of SNOMED CT is to index, store, and retrieve information about a patient in an electronic health record. SNOMED CT is known to currently contain 300,000 medical concepts, which provides standard by which medical conditions and symptoms can be referred, eliminating the confusion that may result from the use of regional or colloquial terms. Giannangelo (2010), states that the SNOMED CT structure consists of four

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