ABSTRACT

The electronic medical record (EMR) is an electronic means for physicians and other clinical providers to review clinical results, place patient orders, and create appropriate electronic documentation. The EMR actions on the part of physicians include computer order entry (CPOE) and electronic documentation. CPOE is not keyboarding orders as free text into a word processor, but rather it is the process of retrieving orders from an electronic order catalogue by matching specific catalogue orders to the desired order intent as conceived. CPOE additionally provides the means to make available defined order sets that support integrated tasks into a common complex clinical action. The creation of electronic documentation is the physician's means of providing documentation of history and physical notes, consultations, procedures, operations, progress notes, and discharge summaries, prescriptions, and medication reconciliation. Much of this documentation is free text in nature, but requires adherence to standard formats.