Your EMR

Anything from an annual wellness exam with your primary care doctor to an ambulance run following a serious accident or illness is etched into your computerized “healthcare book of life.” Depending upon how many different health care providers you interact with, your medical history could be logged into multiple EMRs, each with a different piece of your medical history.

The conventional EMR may include most if not all of the administrative, legal, and clinical data that pertains to a particular provider encounter. Those records may include patient demographics, a list of “problems” the patient is complaining about, progress notes, hospital admission notes, surgical reports, pathology results, medications, past medical history, immunizations, and lab and radiology reports. Even an overnight hospital admission for a diagnostic or surgical procedure can generate dozens of pages of records.   

The EMR exists for obvious reasons, with the main goals being providing the best care possible to the patient and reducing the incidence of medical errors from transcription mistakes. It also makes the patient’s health information available across the spectrum of providers so that everyone is on the same page.   

Do mistakes happen? Yes, but not often, fortunately. That becomes an important consideration when reporting a medical history on the MedXpress 8500-8 application. A first-time “yes” response to any of the items in section 18 of the application may prompt the FAA to reach out for more information, even after the AME issued you a medical.

If the request is for a “detailed clinical progress note” or other specific medical records, and those records include any incorrect medical information, it could create more issues before things get sorted out. Be sure you read all the medical documents your provider generates in the EMR and reconcile them for accuracy. If you see something that isn’t accurate, get with the provider and ask for an addendum that corrects the error and include that with what is being sent to the FAA. 

As a participant in the AOPA Pilot Protection Services Plus level, our medical certification staff can review any records before you send them to the FAA. That extra set of eyes on the records can help assure that what you’re providing to the FAA will result in a good outcome.

aopa.org/pps