Electronic health record (EHR): why it matters

The electronic health record (EHR) is the main tool for recording clinical, care and administrative information in the healthcare system. More than a tool for digitizing healthcare, it is a strategic mechanism for healthcare management.

Its legal, regulatory and operational requirements directly affect care, auditing and hospital billing.

What is an electronic health record (EHR)?

The electronic health record is the set of digital information that documents a person’s entire care journey. It includes the history of visits and diagnoses, prescriptions, tests and care outcomes.

The EHR is made up of structured fields, digital documents, electronic signatures, audit trails and security mechanisms that ensure the integrity, authenticity and traceability of information.

The main items to be filled in are:

• recording the patient history, physical examination and clinical variables;

• prescribing medications or other therapeutic methods;

• issuing medical certificates and other clinical documents;

• ordering tests and other complementary diagnostic methods;

• referrals to other points of the healthcare network;

• quick access to current health problems and interventions.

Advantages of the EHR over the paper record

The main advantages of the EHR over the paper medical record are:

1. Availability and multidisciplinary access

In the paper model, the medical record is a single object: if nursing has it, the physician cannot consult it. With the electronic record, access is simultaneous and remote. Several professionals (physician, physical therapist, nutritionist and auditor) can view and update the patient’s history at the same time, from different locations in the facility, which speeds up clinical decision‑making.

2. Patient safety and legibility

In the popular imagination, many doctors have illegible handwriting. Since this can actually happen, it is a risk of the paper record that can lead to serious medication administration errors. The EHR eliminates this problem and adds smart layers of safety, such as automatic alerts for allergies or dangerous drug interactions at the moment the prescription is typed.

3. Space optimization and cost reduction

Keeping a physical archive requires large climate-controlled areas, folders, paper and staff dedicated solely to organizing and retrieving documents. The transition to digital frees up that space for care areas (new beds or exam rooms) and drastically cuts operating costs for printing supplies.

4. Traceability and legal validity

While on paper it is hard to know who accessed the chart or whether a page was removed, the EHR generates access logs (digital trails). Every entry is stamped with the date, time and identity of the professional. With digital certification (ICP-Brasil, the Brazilian Public Key Infrastructure), the document gains full legal validity and is therefore harder to dispute or forge than a handwritten signature.

5. Faster auditing and billing

For hospital billing, the paper record is a bottleneck: you have to wait for the patient’s discharge and the physical delivery of the folder before the review can start. With the EHR, auditing can be done in real time (concurrent audit). This makes it possible to identify documentation gaps even before the patient leaves the hospital, drastically reducing the denial rate and improving cash flow.

6. Data preservation and longevity

Paper yellows, tears, molds and can be destroyed by fire or flooding. The electronic record relies on backup routines and cloud storage, ensuring that the patient’s history is preserved for decades, as required by law, with no degradation of information.

Electronic and paper medical records: a summary of the main differences

Is the EHR mandatory in Brazil?

In Brazil, there is no single required model for electronic health records, but there are rules that govern their use. The Federal Council of Medicine (CFM) establishes that the patient’s medical record is mandatory, regardless of the medium used, paper or electronic. For electronic records, specific rules apply regarding digital certification, document retention and confidentiality of information.

In addition to CFM rules, the use of electronic records must comply with the General Data Protection Law (LGPD), which classifies health data as sensitive personal data and imposes obligations on processing, security and access. ICP-Brasil rules, which govern the use of legally valid digital signatures, are also relevant.

Why the electronic record matters for auditing and billing

The electronic record plays a central role in care auditing and billing processes. Incomplete, inconsistent or untraceable records make it harder to prove the care provided and increase the risk of denials, queries and financial losses.

In internal and external audits, the EHR is the main source of evidence to validate diagnoses, procedures, materials used and length of stay. Properly structured fields, standardized progress notes and correct links between clinical records and charges are decisive factors for revenue cycle compliance.

Example of an electronic health record

Below is a model electronic record in table format, focused on regulatory compliance, auditing and billing.

In this context, the electronic record is no longer just a repository of clinical information and takes a central place in the care and financial governance of healthcare institutions.

The Rivio view

The electronic record should be treated as a strategic asset of the hospital revenue cycle. Applying artificial intelligence to structured clinical data makes it possible to identify documentation nonconformities, cross-check care records against charges and support audit processes systematically.

Advanced use of the EHR contributes to greater operational efficiency, fewer denials and stronger clinical and financial governance at healthcare institutions.