La historia clínica electrónica. Revisión y análisis de la actualidad. Diraya: la historia de salud electrónica de Andalucía

There is no doubt that the medical record lies at the heart of all clinical information on the patient and, in addition, provides the basis for communication between different professionals involved in the patient's care. It is important that any terminological information included in electronic medical records is defined beforehand so that it can be subsequently processed and made use of. The tools for processing terminological information in electronic medical records are based on classification languages that facilitate disease classification and coding. In the future, the trend will be towards the compilation of different classification languages so that professionals will be able not only to browse medical records but also to access literature databases and tools that can aid decision-making. The influence of electronic medical records on the quality of healthcare provision has been the focus of a number of publications, which have produced variable results due to methodological problems. The most important benefits are better adherence to clinical practice guidelines and a reduction in the number of prescription errors.