What is an Electronic Medical Record (EMR)?
An electronic medical record (EMR) contains information about a patient’s health history including diagnoses, prescriptions, test results, allergies, immunizations and other treatment details. The hospital EMR is the digital equivalent of your medical “chart”.
Your hospital EMR can help you check that you have been billed correctly for the medical services you received. It can also provide evidence of medical necessity in the case of a denied claim.
How do I get my hospital Electronic Medical Record?
To obtain your EMR, call the hospital or provider directly and request that they send you your Electronic Medical Record. They are required by law to send your EMR upon request.
Understanding your Electronic Medical Record
Electronic Medical Record formats will vary depending on your provider. If you are having trouble using the information in your hospital EMR to lower your medical bills, consider working with a medical billing advocate. Typical items seen on your EMR chart include:
- Medical Problems
- Family History
- Social History
- Allergies and Adverse Reactions
- Medications
- Immunizations
- Vital Signs
- Procedures
- Test Results
- Assessments
- Plan of Treatment
- Referrals
The Electronic Medical Record Terminology to Know
- Electronic Health Record (EHR): The terms EHR and EMR are sometimes used interchangeably. EHR generally refers to digital records that are more portable across providers and include more varied information sources than an EMR.
- Medical Chart: Prior to the creation of electronic medical records, your healthcare history was logged in your “chart”, a paper based record maintained by your provider. You may hear doctors or nurses refer to your medical history this way even though your medical records are now kept electronically.
Electronic Medical Record Tips
- Hospital EMR descriptions can be confusing. Consult Healthcare Blue Book to learn more.
If you need help obtaining your hospital EMR to use the information to lower your medical bills, get in touch with our medical bill advocates at Resolve today.