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The Electronic Health Record (EHR) is defined as a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow.

The Electronic Health Record (EHR) is defined as a longitudinal electronic record of patient health information generated by one or more encounters in any care

100 common intervention terms used in clinical documentation. Looks pretty helpful for the less appealing part of our jobs...

100 common intervention terms used in clinical documentation. Looks pretty helpful for the less appealing part of our jobs.

Successful collaboration in healthcare : a guide for physicians, nurses and clinical documentation specialists (2010). Colleen Stukenberg

Successful collaboration in healthcare : a guide for physicians, nurses and clinical documentation specialists Colleen Stukenberg