Charting in the Electronic Health Record (EHR)

Vocabulary flashcards reviewing EHR charting concepts, documentation roles, release of medical records, advanced directives, and vital signs.

Electronic Health Record (EHR) Charting

The process of documenting patient care digitally, which replaces traditional paper charts and ensures accurate, real-time data sharing among healthcare providers.

Key Components of EHR Charting

Patient demographics, medical history, progress notes, medications and allergies, lab and diagnostic results, care plans, and orders.

Importance of EHR Charting

Enhances patient safety and care quality, improves communication among healthcare teams, provides legal documentation of care, facilitates billing and coding accuracy, and supports research and analytics.

Medical Assistant EHR Role

Checks vital signs, gathers relevant information including current allergies and medications, and documents this information into the EHR during the visit.

Provider EHR Role

Reviews the EHR, examines the patient, documents visit findings, and electronically orders tests and medications.

Best Practices for EHR Charting

Documenting promptly and accurately, using clear and professional language, avoiding copy-paste errors, maintaining patient confidentiality, and following institutional policies.

Release of Information (ROI)

A process where patients request to release information in their electronic medical record, specifying the recipient, information to be disclosed, consenting party, and date/signature.

ROI Provider Exception

Information sharing between providers who are both treating the same patient, which does not require patient consent or a signed ROI.

Advanced Directives

Medical instructions in patient records that include DNR (Do Not Resuscitate), DNI (Do Not Intubate), and Full Code (Perform CPR).

DNR

Do Not Resuscitate.

DNI

Do Not Intubate.

Full Code

Perform CPR.

Main Vital Signs

BP (Blood Pressure), T (Temperature), P (Pulse) / HR (Heart Rate), R (Respirations), and SpO2 (Pulse Oximetry).

Secondary Vitals

Pain, height, and weight.