What it means
The computer system that holds a client's history, orders, medications, results, notes and care plans. It lets providers in different places see the same information, checks for drug allergies and interactions, and supports barcode medication scanning. The terms EHR and electronic medical record (EMR) are often used for the same thing.
For the nurse
Log out whenever you leave the screen, never share passwords, and open only the records of clients in your care. Chart in real time and correct errors the way the system allows, never by deleting.
At a glance
| Abbreviations | EHR; EMR |
|---|---|
| Also written | EHR, EMR, electronic medical record, electronic health records, electronic medical records |
Related terms
medical record
The legal record of a client's health history, care, tests and treatment, also called the chart.
medication reconciliation
Comparing a client's full list of current medicines with new orders at each change in care, to find and fix differences.