Many electronic medical records software systems function on the basis of templates, which the physician or staff member selects and fills in according to the specifics of that particular case. For example, in the emergency room, a patient might arrive with chest pain. The person creating the medical record will choose the "chest pain" template, which will provide appropriate blanks and prompts for the recorder to fill in that patient's medical history, history of present complaint, physical exam, lab tests and results, and interventions taken.
HIPAA has had a huge impact on the world of EMR. Healthcare professionals themselves were the ones to push for the first part of HIPAA Title II, the Administrative Simplification. The goal is to standardize EMR and coding, making EMR not only confidential but also interoperable. Patients' EMRs need to be accessible easily when the patient has given medical professionals permission to access them.
The federal government as well as professional organizations and individual healthcare facilities are hard at work to achieve a greater level of interoperability with EMR.
The most advanced EMR systems are compatible with billing software, simplifying the connection between billing and records.