Electronic Health Records (EHRs) and Coding for Patient-Centered Care: Documentation, Retrieval, Quality, and Reference Use

Electronic Health Record (EHR)

A digital version of a patient’s health information used by healthcare organizations to support clinical care, communication, billing, and legal documentation.

Structured Data

Information entered into defined fields like checkboxes, which is easy for systems to process and analyze.

Narrative (Free Text)

Information written in prose, capturing details and context that structured data may miss.

Continuous Care

The seamless transfer and understanding of patient information among clinicians to ensure safe and efficient care.

Audit Trail

A log within EHRs that tracks who accessed patient information and what actions were taken.

ALCOA Concept

Principle stating health data must be Attributable, Legible, Contemporaneous, Original, and Accurate to maintain integrity.

Data Quality

The accuracy, completeness, and timeliness of data, ensuring it supports safe patient care.

Compliance in EHR

Adherence to laws, regulations, and organizational policies regarding patient data privacy and security.

Data Integrity

Ensuring information remains correct and unaltered through appropriate tracking and attribution.

Copy-forward

An EHR feature that allows the repetition of previous notes in new documentation, which can carry outdated information.

Patient Engagement

The involvement of patients in their care decisions, often facilitated by shared access to EHRs.

Clinical Decision Support (CDS)

EHR features that provide alerts and reminders to support clinical decision-making.

Minimum Necessary Access

The principle of accessing only the patient information needed to perform a specific job function.

Templates in EHRs

Predefined formats used in documentation that can enhance efficiency but may lead to incomplete records.

Electronic Signature

An electronic authentication required by EHR systems to validate a document entry.

Patient-centered Care

Healthcare that respects and responds to individual patient preferences, needs, and values.

Duration of Access Log

Record of how long a user's session lasts when accessing EHRs, contributing to tracking data access.

Clinical Reasoning

The cognitive process clinicians use to make clinical decisions based on patient information and clinical guidelines.

Encounter Context

The specific circumstances and details surrounding a patient visit or interaction with healthcare providers.

Health Information Exchange (HIE)

Inter-organizational sharing of patient health data to improve care coordination.

Reference Material in EHR

Trusted informational resources available within an EHR to aid in clinical decision-making.

Coding in EHR

The process of translating clinical documentation into standard codes for billing and analysis.

Patient Education Library

A collection of materials within the EHR meant for educating patients on their health conditions.

Clinical Guidelines

Systematic recommendations to assist healthcare professionals in making clinical decisions.

Documentation Error Correction

The procedure for addressing errors in EHRs through addenda or corrections, not deletions.

Chart Scavenger Hunt

The inefficient search process of navigating an EHR to find necessary patient information.