Components of Patient Care Care of the Individual

Individual patient care will continue to be at the heart of what we do as family physicians. Documenting, organizing and transmitting the record of patient care over time must be well done, efficient, and communicated clearly to others. Electronic health records should help physicians document an accurate and complete account of the patient's care, including history, physical findings, laboratory tests, imaging results, advice from other specialists, medications, preventive measures, and screening efforts. A problem and medication list helps to present this information in a tabular form for easy reference and summarizes most of the important information that should accompany the patient wherever he or she receives care. The personal health record should capture the majority of this information so that all providers have access, as needed.

Most EHR systems rely on templates to enter information in discrete, searchable fields. There is always tension between the need for providing sufficient detail (granular data) and the burden of entering too much detail without additional benefit to patients or physicians. At times, free text may be necessary to communicate precisely what is happening, such as a complex symptom history. Other information, such as routine physical findings, treatment plans, medications, and tests are more useful if entered in a tabular format (granular data) so that they can be identified and used to generate orders, check for allergies or interactions, feed decision support tools, and generate documents for transmission to others.

Personal health records for individuals are critical to ensure that important information about the patients' medical problems, current treatments, usual sources of care, and medications go with them whenever they need evaluation or treatment. Electronic health records should be able to interact with the personal health record to keep it accurate and up-to-date. In essence, the personal health record is a "snapshot" of the EHR at a point in time. It should be updated whenever there are any changes. The Continuity of Care Record (CCR) standard provides a format for the collection and transmission of this important data.

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