Glossary
Electronic health record (EHR)
An electronic health record (EHR) is a digital record of a patient's health information, built up over time from visits across care settings. The federal eCQI glossary also calls it an electronic medical record (EMR), and it is where dictated and typed notes end up.
Updated October 17, 20264 cited facts, each traced to its source
Also called EHR, EMR, electronic medical record.
An electronic health record (EHR) is the digital chart a clinic keeps for each patient. The eCQI Resource Center, a federal quality-measurement resource, defines it as a digital record of a patient's health information created over time from one or more visits and across care settings 1. The same glossary says the record is also called an electronic patient record, electronic medical record or computerized patient record 2.
So EHR and EMR usually mean the same thing in clinical writing. Some organizations use the two names for different scopes, so check the usage in your own setting before you write a policy.
Clinicians spend much of their day in the record
The EHR takes a large share of clinical time. In a 2017 study of primary care physicians at one academic health system, clinicians spent 355 minutes, or 5.9 hours, of an 11.4-hour workday in the EHR on each weekday 3. In a 2016 time and motion study of physicians in four specialties, 27.0 percent of the office day went to direct face time with patients, and 49.2 percent went to EHR and desk work 4.
A concrete example
A physician dictates a visit note on a phone between patients. The recognized text is placed into the progress note field of the patient's record. The physician reads it, corrects a medication name, and signs the note. The signed note then appears in the chart the next time anyone opens that patient's record.
Why it matters for dictation and typing
Dictation and typing are two ways of getting text into the EHR. Speech can produce a draft quickly, but the text still has to land in the right field, be reviewed and be signed. A dictation tool that works outside the record means copying the text across by hand, which is slower and more error-prone.
For that reason, the questions to ask about any dictation product for clinical work include where the text goes, who can read it, and whether it is processed on the device or in the cloud. Privacy rules for protected health information apply to what you dictate as well as to the record.
Related terms
- Medical scribe is a person or AI tool that writes into the record during a visit.
- SOAP note is a common structure for the notes inside the record.
- Pajama time is the record work that spills into the evening.
Guides that cover it
Evidence
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Related terms
- Dictation for Work: Doctors, Lawyers, Writers, StudentsThe topic this term belongs to
- Back-end speech recognitionBack-end speech recognition is a workflow in which the dictated audio is recognized and then edited by someone else, usually a transcriptionist, before it is signed. Its main trade-off is the cost and time of the second pass against the writer's own editing effort.
- CopytakerA copytaker was a typist in a newspaper office who took down stories that reporters dictated over the telephone. The Collins English Dictionary defines the role this way, and it predates the computer-based filing that replaced it.
- Dictation templateA dictation template is a block of text saved under a short spoken phrase, so one phrase inserts the whole block. Dragon calls these auto-texts, and Microsoft's Dragon Medical One guide documents the command that creates one from selected text.
- Front-end speech recognitionFront-end speech recognition is a workflow in which the person who dictates also reviews, corrects and signs the text, instead of passing the audio to someone else. The term is most common in radiology, where it is set against back-end transcription.
- Medical scribeA medical scribe is a person, or more recently an AI tool, that records what happens in a clinical visit and writes it into the chart so the clinician can focus on the patient. The clinician remains responsible for the note and must check and sign it.
- Pajama timePajama time is the record-keeping that clinicians finish after their clinic day ends, often at home in the evening. A 2017 study of primary care clinicians measured 86 minutes of EHR work per weekday after clinic hours.
- Registered Healthcare Documentation Specialist (RHDS)The Registered Healthcare Documentation Specialist (RHDS) is a voluntary credential from AHDI for people who create healthcare documentation. It is awarded after an exam of 120 questions, and it is a prerequisite for the CHDS.
- ScopistA scopist edits the transcripts of official proceedings that court reporters create. Scopists are typically paid by the page, starting from $1.00 to $1.50 per page, and the role is also called transcript editor.
- SOAP noteA SOAP note is a structured clinical note with four parts: Subjective, Objective, Assessment and Plan. The format was developed by Larry Weed, and a StatPearls reference article describes it as a widely used documentation method for clinicians.
- Transcription line rateA transcription line is a unit of 65 characters, and the line count is the number of such units in a document. The transcription line rate is the price paid for each line, so the unit controls how transcribed work is measured.
Pages that use this term
- Dictation for Work: Doctors, Lawyers, Writers, StudentsTopic
- Medical Dictation: Software, Devices and How It WorksGuide
- AI Medical Scribes and Ambient Clinical DocumentationGuide
- How do you dictate SOAP notes?Question
- How much time do doctors spend on documentation?Question
- Should doctors use an AI scribe or dictation?Question
- What is an ambient AI scribe?Question
- Why do doctors dictate their notes?Question
- Dragon Medical OneGlossary
- Medical scribeGlossary
- Pajama timeGlossary
- SOAP noteGlossary