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EMR/EHR Glossary

Clear definitions for the terms used.

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Allergies Clinical
Structured list of adverse reactions (e.g., drug, food) captured per patient. Used by clinical decision support to alert on contraindications.
Appointment Admin
Scheduled encounter between a patient and provider, with status (booked/arrived/no‑show), location, and assigned resources.
Audit Log Security
Tamper‑evident record of who accessed or changed what and when (read/write/delete), used for compliance and security investigations.
CPT / ICD‑10 Admin
Procedure and diagnosis code sets used for documentation and claims. Local equivalents may apply.
Encounter Clinical
An interaction between a patient and care team (visit/admission/telehealth) with start/end, type, and participants.
HL7® FHIR® Interop
Modern healthcare data exchange standard with resources (Patient, Encounter, Observation) and REST APIs.
LOINC Interop
Code system for lab tests and clinical observations, enabling consistent ordering and results mapping.
Medication Clinical
A drug product with strength, form, and route. May be prescribed, administered, or reconciled.
MRN (Medical Record Number) Admin
Unique identifier for a patient’s record within a facility or system; distinct from visit/encounter IDs.
Observation Clinical
Measured or asserted clinical data point (e.g., vital sign, lab result) with value, unit, and reference range.
Order Clinical
Request for a service (lab panel, imaging, medication) including priority, status, and performer.
PHI / PII Security
Protected/Personal information that can identify a person. Requires strict access controls, logging, and minimization.
Problem List Clinical
Curated list of active and resolved conditions relevant to ongoing care.
RBAC (Role‑Based Access Control) Security
Authorization model where permissions are attached to roles (e.g., Nurse, Billing), then granted to users.
SOAP Note Clinical
Documentation pattern: Subjective, Objective, Assessment, Plan—used in progress notes.

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