An electronic health record is the digital system holding a patient's clinical documentation, orders, results, and medication administration. It captures far more than the printed chart, including access logs, entry timestamps, amendments, and clinical decision support alerts.
Printed or PDF exports typically omit this underlying metadata.
Alternative Names:
EHR, Electronic Medical Record, EMR
Why it Matters?
The gap between the printed chart and the underlying system is where meaningful evidence sits. A record showing a normal assessment reveals something different when the audit trail shows it was entered eight hours later, after the adverse event. Requests should specify the audit trail and metadata explicitly, because a request for the medical records will produce a flattened export that contains none of it.
Frequently Confused with
Related terms
Frequently asked questions
Does a printed chart contain everything in the EHR?
How should EHR data be requested?
