2025
Overview
Electronic medical record systems are digital platforms that store, manage, and share patients' health information, replacing paper charts and supporting documentation, ordering, decision support, and information exchange across clinical care. They matter because well-designed records can improve safety, coordination, and continuity of care, while poorly standardized data and workflows can introduce risks such as alert fatigue, provider burden, and medication errors. A central challenge in these systems is the consistent capture and codification of clinical information, including adverse drug events and medication data, where inconsistent definitions, documentation practices, terminology standards, and interoperability limit the usefulness of the data for clinicians. Clinical decision support tools embedded in these records aim to inform prescribing and reviewing, but their effectiveness depends on refined definitions, accurate mapping, and standardized terminology. Key aspects include data standardization and codification, interoperability between systems, clinical decision support design, documentation workflows, and patient-safety outcomes. Related open-access research, including a call to action on standardizing and codifying adverse drug event definitions, documentation, and mapping within electronic health records, is available in this collection.
Research published in this journal
1 peer-reviewed article, ranked by relevance. Each links to its DOI.