Charting in the Electronic Health Record (EHR)

Vocabulary flashcards covering key components, best practices, legal directives, vital signs, and workflows for EHR charting.

Charting in the Electronic Health Record (EHR)

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

Key Components of EHR Charting

The patient data sections within an EHR, which include patient demographics, medical history, progress notes, medications and allergies, lab and diagnostic results, and care plans and orders.

Importance of Charting in EHR

The core benefits of digital charting: enhancing patient safety and care quality, improving communication among healthcare teams, providing legal documentation, facilitating billing and coding accuracy, and supporting research and analytics.

Best Practices for Charting in EHR

Guidelines for proper documentation, which require charting promptly and accurately, using clear, professional language, avoiding copy-paste errors, maintaining patient confidentiality, and following institutional policies.

Release of Information (ROI)

A patient's formal request to release information in their electronic medical record, specifying the person receiving info, info to disclose, consenting authority, and date/signature. It is not required for provider-to-provider sharing when treating the same patient.

Advanced Directives

Legal instructions regarding emergency care preferences, which include DNR (Do Not Resuscitate), DNI (Do Not Intubate), and Full Code (Perform CPR).

DNR

Do Not Resuscitate; an advanced directive stating that resuscitation procedures should not be performed.

DNI

Do Not Intubate; an advanced directive specifying that endotracheal intubation should not be performed.

Full Code

An advanced directive ordering healthcare providers to perform CPR in the event of cardiac or respiratory arrest.

Main Vital Signs

Primary quantitative physiological measurements in patient exams, including BP (Blood Pressure), T (Temperature), P (Pulse/HR-Heart Rate), R (Respirations), and SPO2 (Pulse Oximetry).

Secondary Vitals

Additional clinical indicators evaluated alongside main vital signs, comprising Pain, as well as Height and Weight.

Patient Exam Documentation Workflow

The process where a Medical Assistant checks vital signs and gathers allergies and medications into the EHR during the visit, after which the Provider reviews the record, examines the patient, documents findings, and electronically orders tests and medications.