Healthcare Systems, Health Records and Medical Terminology · 4 min read
Health Records and the Electronic Health Record
This chapter covers the formats in which health records are kept, the difference between an EHR, an EMR and a PHR, and the main parts of an electronic health record that an MAA works with every day.
Types of Health Records
A health record is the documented account of a patient's health history and care. It is a legal document. It supports treatment, communication among providers, billing and legal defense.
Health Record Formats: Pros and Cons
| Format | Advantages | Disadvantages |
|---|---|---|
| Paper | Low startup cost; works during power outages | Hard to read, easy to misfile, one copy in one place, needs storage space |
| Electronic, computer-based | Legible, searchable, supports alerts and reports | Costly to set up; needs training and backups |
| Web-based | Accessed through a browser from approved locations | Depends on internet connection and strong security |
| Cloud-based | Vendor hosts data on remote servers; automatic updates and backups | Ongoing subscription; vendor must sign a business associate agreement |
| App or mobile | Patients and staff view data on phones and tablets | Small screens; lost devices are a privacy risk |
Paper charts still appear in some small offices and during downtime. Electronic systems dominate because they reduce handwriting errors, allow several people to view a chart at once and make it easy to find information. A computer-based record lives on servers the practice owns; a web-based or cloud-based record is hosted elsewhere and accessed over the internet. Any electronic system must be protected with unique logins, automatic log-off and regular backups.
EHR vs EMR vs PHR
These three terms appear often on the exam, and the differences are simple once you see them side by side.
Comparing EHR, EMR and PHR
| Record | Who Controls It | Key Feature |
|---|---|---|
| Electronic medical record (EMR) | One practice or facility | Digital version of the chart within one organization |
| Electronic health record (EHR) | Healthcare organizations, shared among authorized providers | Designed to share data across practices, labs, hospitals and pharmacies |
| Personal health record (PHR) | The patient | Patient manages and adds information, such as through a portal or app |
An EMR is like a paper chart turned digital: useful inside one office but not built to travel. An EHR follows the patient. When a cardiologist orders a test, the result can flow to the PCP's EHR. A PHR belongs to the patient, who may record home blood pressure readings, upload records or track vaccines.
Exam Tip: When a question emphasizes sharing information among multiple providers and organizations, the answer is EHR. When it emphasizes that the patient maintains the record, the answer is PHR.
Components of the EHR
EHR Components and What They Hold
| Component | What It Contains | Who Typically Enters It |
|---|---|---|
| Demographics | Name, date of birth, address, phone, emergency contact, insurance | MAA at scheduling and check-in |
| Problem list | Current and past diagnoses and conditions | Provider |
| Medication list | Current medications, doses and frequency | Clinical staff and provider |
| MAR | Medication administration record: drugs given in the office or facility, with time and initials | Clinical staff |
| Allergies | Drug, food and environmental allergies and reactions | Clinical staff, verified by provider |
| Orders | Lab tests, imaging, referrals, prescriptions | Provider |
| Results | Lab values, imaging reports, pathology | Received from labs and facilities |
| Progress notes | Provider documentation of each visit | Provider |
| Billing | Charges, codes, payments, balances | Billing staff and MAA |
The MAA's main area is demographics, insurance, scheduling and billing. The MAA may see clinical sections when scanning documents or attaching outside reports, but the MAA does not interpret or change clinical entries. If a patient says an allergy is listed incorrectly, the MAA passes that information to clinical staff rather than editing it.
Common Trap: An answer choice may suggest the MAA "update the allergy list because the patient said so." That is outside the MAA's role. The best answer routes clinical information to the clinical staff or provider.
Front Desk Scenario: Mr. Diego Ramírez calls Lakeshore Orthopedics to say he moved. The MAA verifies his identity with his full name and date of birth, then updates the address and phone number in the demographics section. The MAA confirms the new information by reading it back to him. Demographic updates are squarely within the MAA's role.
Key Takeaways
A health record is a legal document that supports care, communication, billing and legal defense.
Electronic records are legible and searchable but need security, training and backups.
EMR stays within one organization; EHR is shared among providers; PHR is controlled by the patient.
The MAA manages demographics, insurance, scheduling and billing entries.
Clinical entries such as allergies, medications and results are handled by clinical staff and providers.
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