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The Medical Record in Its Evolution: From Paper to Electronic

Even in the healthcare sector, the process of dematerialization is underway, with consequent digitalization, which, little by little, will allow us to abandon the traditional medical record in paper format and move on to the electronic (digital) one. The evolution closely concerns medical practices and clinics, dealing with innovations that mark the daily activities and services carried out for patients.

This article highlights the growth transformation from the traditional method to the electronic medical record and points you to a reputable medical EMR system.

The Medical Record: From Paper to Digital Format

The change concerns the medical record format without prejudice to the data’s nature and the collection’s purpose. In fact, the point of reference, both for public hospitals and for private healthcare facilities, from specialist clinics to polyclinics, remains the definition of medical records given by the Ministry of Health.

The medical record is and remains “the individual information tool aimed at detecting all significant demographic and clinical information relating to a patient and a single episode of hospitalization.” The standard is that each hospital medical record must represent the entire episode of hospitalization of the patient in the healthcare institution.

It coincides with the history of the patient’s stay in the hospital. Thus, the hospital medical record begins at the moment of the patient’s admission, ends at the moment of the patient’s discharge, and follows the patient throughout his journey within the hospital structure.

What Information Is Contained in the Medical Record

The same applies to keeping medical records by doctors involved in specialist practices and clinics. The medical record must contain all information relating to the patient, from personal details to clinical information. To use strictly journalistic language, we can also say that all the answers to the five questions must be noted.

They are the so-called five Ws, which are the basic rules in writing every article for reporters. Likewise, the medical record must indicate who, what, when, why, and how regarding the patient’s health care.

Therefore, the extreme importance of keeping and subsequently conserving medical records by medical practices and clinics is evident. The document, in fact, constitutes the basis for guaranteeing the patient all the care he needs so that the right to health, which, in our system, is guaranteed by regulation, finds concrete application.

Furthermore, the medical record allows immediate communication between the healthcare professionals involved in patient care: a person may have been treated in other clinics or specialist medical practices. It is possible that the person is being treated at multiple healthcare facilities for different pathologies.

Sensitive Data and Privacy Protection

So, what should be reported in the medical record? After indicating the identifying data, the pathologies, the therapies prescribed, those already carried out, planned, and possibly suspended and postponed, medications, allergies, hospitalizations in healthcare facilities, and surgical interventions must be reported. In short, everything that concerns the patient’s history.

The information contained in the medical record, therefore, must be such as to support diagnosis and treatment and must document the course of the pathology. This allows the doctor’s office or clinic to constantly monitor and establish any corrective measures if necessary. Given that the medical record constitutes the main source of information, it is clear how valuable it is for preventing and reducing the risk of error in the healthcare sector.

Considering the uniqueness of this information, medical records must meet certain requirements established by the legislator: security and confidentiality. In fact, these are so-called sensitive data which, as such, must be protected in such a way as to avoid their dissemination for purposes other than strictly healthcare ones.

The Benefits of Digital Health Records for Patients and Doctors

At this point, you must ask yourself what digital medical records’ advantages are. First of all, the electronic format allows a significant saving of paper, with positive consequences in terms of respect for the environment and time.

In fact, time is also an important resource for medical practices and clinics: it’s one thing to go to the archive and search through the folders for the medical record you’re interested in, but it’s another to have everything at your fingertips, or rather just a click away. According to the manual, the transition to the electronic medical record has produced a 13 percent time-saving in the activity carried out.

Not only that, but all the information in an electronic medical record becomes accessible in real-time to multiple doctors, thus making collaboration between specialist medical practices or clinics much simpler, more immediate, and more effective. This is to the patient’s benefit.

The electronic medical record has an important impact in terms of reducing the prescription of diagnostic tests: “The use of the computerized medical record has reduced the number of inappropriate prescriptions by 14 percent”. And it improved the satisfaction level with the service offered by doctors and patients, who showed satisfaction with the streaming of administrative procedures (25 percent of a doctor’s activity).


In the transition to digital, even for medical practices and clinics, management software constitutes precious allies because it allows access to medical records at anytime and anywhere extremely quickly. Hence, if you want to use EMR systems, you must find secure and trusted EMR medical software. In that case, we recommend you opt-in for the services of Calvin EMR software.

Christopher Stern

Christopher Stern is a Washington-based reporter. Chris spent many years covering tech policy as a business reporter for renowned publications. He has extensive experience covering Congress, the Federal Communications Commission, and the Federal Trade Commissions. He is a graduate of Middlebury College. Email:[email protected]

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