How to Use an EMR System: Everyday Tasks and Safety

Operating an electronic medical record (EMR) system means using its approved workflows to document care, manage information, and complete follow-up tasks. The exact screens and features vary by product and practice. Use your organization’s training and policies for clinical decisions, orders, corrections, and access; this guide is a general workflow overview, not a substitute for vendor-specific instructions.

Typical steps in an EMR visit

Sign in with your own account. Use the access method and permissions assigned to your role. Do not share credentials or use another person’s session. If your access is incorrect, request a change through the designated administrator.
Find and verify the patient. Search using the practice’s approved identifiers and confirm the record before opening or entering information. Pause if details do not match; do not create a duplicate chart as a workaround.
Open the correct encounter. Confirm the visit date, type, location, and status. Review relevant chart sections available to your role, such as allergies, medications, history, and prior notes, while following the practice’s workflow.
Document the encounter. Use the approved note or template, distinguish patient-reported information from observed findings, and make sure the entry reflects the visit. Avoid copying forward content without checking that it remains accurate.
Review before signing or closing. Check patient and encounter context, required fields, and any tasks assigned to you. Sign, save, route, or close only as permitted by your role and local policy. Some systems treat a signed note as a legal record and require a formal amendment rather than silent editing.
Complete follow-up work. Depending on the system and your responsibilities, this may include routing a note, assigning a task, tracking a result, or arranging a follow-up. Confirm ownership and status in the system rather than assuming that saving a note completes every workflow.

Other common EMR tasks

Registration and scheduling

Front-office workflows may include creating or updating demographic details, documenting the source of information, checking for possible duplicate records, scheduling visits, and recording arrival. Follow the organization’s identity-matching and correction procedures; technology settings alone do not prevent patient mix-ups.

Finding information and managing tasks

Use the system’s authorized search, inbox, task list, or reporting tools to locate information you need for your role. Check dates, status, and encounter context. If a result or message appears incomplete or is routed to the wrong person, use the practice’s escalation process.

Correcting an entry

Do not erase, backdate, or overwrite a clinical record outside the approved correction process. Systems differ, but corrections commonly preserve an audit trail. Ask the records administrator or supervisor how to amend a signed note, fix a demographic error, or handle information entered on the wrong chart.

How to learn an EMR safely and efficiently

Ask for role-specific training and practice in a test or training environment when available.
Learn the organization’s patient-identification, documentation, correction, privacy, and downtime procedures.
Practice the tasks you perform most often, including the less frequent exception paths.
Know where to get help, report a system problem, and find approved downtime forms and recovery steps.
Share workflow friction with the implementation or system-administration team; do not independently change templates, permissions, or clinical decision support.

ONC’s SAFER Guides offer practical self-assessment resources for organizations working on EHR implementation and safe use. The Patient Identification guide emphasizes that reliable identification depends on both system design and staff processes and training; the Contingency Planning guide addresses planned or unplanned system unavailability. Read ONC’s implementation guidance and review guidance for using health IT.

Frequently asked questions

Is an EMR the same as an EHR?

The terms are often used interchangeably in everyday conversation. In general, “EMR” may refer to a digital record used within a practice, while “EHR” often emphasizes information that can support care across organizations. Product terminology and capabilities vary, so check the system’s documentation and interoperability functions.

Can every staff member see or change the same information?

No. Access and editing permissions should be assigned according to role and organizational policy. If you need information or a function to do your job, request the appropriate access instead of borrowing another user’s account.

What should I do if the EMR is unavailable?

Follow your organization’s downtime plan, including approved documentation and communication steps. Once service returns, use the designated process to reconcile information and avoid duplicate or conflicting entries. Do not improvise a workaround involving unapproved devices or channels.

For related background, see what an EMR is, how ambulatory and inpatient EHRs differ, and EHR technology requirements.