SnorreFossland
commented
1 year ago EHR Note attributes
Patient Information: This includes the patient's name, date of birth, gender, address, contact information, and insurance details.
Date and Time: The date and time of the EHR note creation, as well as the date and time of the patient's appointment or encounter.
Provider Information: The name, title, and contact information of the healthcare provider who created the EHR note, as well as the name and contact information of the healthcare facility.
Chief Complaint: The primary reason for the patient's visit or encounter, as described by the patient.
History of Present Illness: A detailed description of the patient's current symptoms, including the onset, duration, severity, and any factors that may aggravate or alleviate the symptoms.
Past Medical History: A summary of the patient's previous medical conditions, surgeries, hospitalizations, and any ongoing treatments or medications.
Family History: A summary of the patient's family medical history, including any genetic or hereditary conditions.
Social History: A summary of the patient's lifestyle, including occupation, living situation, substance use, and any other relevant factors that may impact their health.
Review of Systems: A comprehensive review of the patient's body systems, including any symptoms or concerns related to each system.
Physical Examination: A detailed description of the healthcare provider's findings during the physical examination, including any abnormalities or concerns.
Assessment: The healthcare provider's evaluation of the patient's condition, including a diagnosis or differential diagnosis.
Plan: The healthcare provider's recommended course of action, including any treatments, medications, referrals, or follow-up appointments.
Medications: A list of the patient's current medications, including the name, dosage, frequency, and duration of each medication.
Allergies: A list of the patient's known allergies, including the type of reaction and severity.
Immunizations: A record of the patient's immunization history, including the type of vaccine, date administered, and any adverse reactions.
Laboratory and Imaging Results: A summary of any laboratory tests or imaging studies performed, including the results and any significant findings.
Consultations: A record of any consultations with other healthcare providers, including the reason for the consultation and the outcome.
Patient Education: A summary of any education or counseling provided to the patient, including the topics discussed and any resources provided.
Signature: The healthcare provider's signature, indicating that they have reviewed and approved the EHR note.
Electronic health record attributes (EHR)
Patient demographics: This includes the patient's name, date of birth, gender, race, ethnicity, and contact information.
Medical history: A comprehensive record of the patient's past medical conditions, surgeries, hospitalizations, and treatments.
Medications: A list of all current and past medications prescribed to the patient, including dosages, frequency, and duration of use.
Allergies: Information about any known allergies the patient has, including reactions and severity.
Immunizations: A record of all vaccinations the patient has received, including dates and types of vaccines.
Laboratory results: Results from any laboratory tests, such as blood tests, urine tests, and imaging studies.
Vital signs: Measurements of the patient's vital signs, such as blood pressure, heart rate, respiratory rate, and temperature.
Problem list: A list of the patient's current and past medical problems, including diagnoses and dates.
Clinical notes: Notes from healthcare providers detailing the patient's symptoms, physical examination findings, assessment, and treatment plan.
Care plans: Documentation of the patient's individualized care plan, including goals, interventions, and progress.
Social history: Information about the patient's lifestyle, such as smoking status, alcohol use, exercise habits, and occupation.
Family history: A record of the patient's family medical history, including any genetic predispositions to certain conditions.
Insurance information: Details about the patient's health insurance coverage, including policy numbers and contact information for the insurance company.
Advance directives: Documentation of the patient's preferences for end-of-life care, such as living wills and durable power of attorney for healthcare decisions.
Consent forms: Records of the patient's informed consent for various treatments and procedures.
Appointment history: A record of the patient's past and upcoming appointments with healthcare providers.
Billing information: Details about the patient's financial responsibility for services rendered, including copayments, deductibles, and outstanding balances.
Referrals and authorizations: Documentation of any referrals to specialists or authorizations for specific treatments or procedures.
Patient communication: Records of any communication between the patient and healthcare providers, such as phone calls, emails, and secure messaging.
Patient education materials: Information provided to the patient about their condition, treatment options, and self-care strategies.