Guided Notes

Clinical Documentation in the EHR

Notes, templates and smart text, flowsheets for structured data, nursing documentation, signing and co-signing, and the balance between structured and narrative data.

Types of clinical documentation

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• Provider notes: H&P, progress notes, consults, procedure notes, discharge summaries, office visit notes. • Nursing documentation: admission assessment, shift assessments, care plans, education, I&O (intake/output). • Flowsheets: rows of structured data over time (vitals, pain, neuro checks, lines/drains/airways). • Questionnaires and forms: screening tools (depression PHQ-9, fall risk, sepsis screening). • Scanned documents: outside records, consent forms.

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