Title: (Optional) Identify the components of the electronic medical record (EMR).
Course: Introduction to Health and Medical Sciences (14001-II) > Section: Performing Administrative Functions in the Healthcare Profession

Identification should include

- patient's demographic data
- physician's medical orders (e.g., medications, treatments, diagnostic tests)
- patient’s history
- physical examinations and/or procedures
- lab and diagnostic tests
- progress notes from the interdisciplinary healthcare team
- legal directives (e.g., advance directives, living wills, DNR orders).

Process/Skill Questions:

- Where would the nurse document his or her patient care?
- Where in the chart is an X-ray report located?
- Where in the chart is a medication order located?
- Where in the chart are doctors’ orders located?
- Who is authorized to view an electronic medical record?
- What are advance directives, DNRs, and living wills?