EHR
A digital version of a persons medical record. It allows secure sharing of information across providers.
Charting
The process of documenting care and observations. Accurate charting supports communication and safety.
Clinical Decision Support
Tools within the EHR that help providers make informed decisions. They may include alerts or reminders.
Order Entry
The electronic process of entering medication or test requests. It reduces errors and improves efficiency.
Health Information Exchange
The secure sharing of health data between organizations. It supports continuity of care.
Template
A structured form used to guide documentation. It helps ensure consistency and completeness.
Audit Trail
A record of who accessed or changed information. It supports security and accountability.
Interoperability
The ability of different systems to exchange information. It improves coordination and reduces duplication.
Data Field
A specific area in the EHR where information is entered. It helps organize and structure data.
User Authentication
A process that verifies identity before accessing records. It protects sensitive information.
Clinical Note
A written entry describing care actions and observations. It becomes part of the permanent record.
Coding
Assigning standardized codes to diagnoses and procedures. It supports billing and data analysis.
Privacy Rule
A regulation that protects personal health information. It sets standards for use and disclosure.
Encryption
A method of securing data by converting it into unreadable form. It protects information during transmission.
Interface
A connection that allows systems to communicate. It helps integrate data from multiple sources.
Alert Fatigue
A condition where frequent alerts reduce attention. It can affect safety and decision making.
Data Migration
The transfer of information from one system to another. It occurs during upgrades or transitions.
Access Level
The amount of information a user is allowed to view. It is based on role and responsibility.
Clinical Workflow
The sequence of tasks in patient care. EHR design should support efficient workflow.
Downtime Procedure
A plan for documenting and accessing information when the system is unavailable. It ensures continuity of care.