The notes section of each medical record is written by a patient’s healthcare professional during hospitalization or outpatient care. Variations in content, formatting, and detail are not barriers to access, as this model allows applications to both read and write notes within a patient’s chart regardless of the clinical situation or information included. In addition to free text notes, some EHRs support integration with discrete notes, where free text responses are associated with specific note fields. This model allows for the inclusion of both.
Functionality: Read and/or Write
Type: Event Based
Key Information Included:
- Patient Identifiers and Demographics
- Provider details of a specific encounter
- Note author and signer
In the clinic or outpatient setting, applications can use the Notes functionality to document and share an event that happened outside the hospital or outpatient setting. These notes will fit seamlessly into the clinician workflow to provide enhanced care.
In the hospital or inpatient setting, this model is commonly used to explain or simplify a patient’s understanding of continued care by giving them direct access to their physician’s instructions.