An electronic health record (EHR) is a longitudinal digital record of a person’s health information. There is no single universal list of ten documents that every EHR must contain. Depending on the care setting and system, a patient record may include demographics, diagnoses, medications, allergies, clinical notes, orders, test results, immunizations, care plans, and supporting documents. These ten common components help explain what people may find in an EHR.
10 common components of an EHR
- Patient demographics and registration details. Identifying and contact information used to match the record to the right person and support registration and communication. Practices should follow their own policies for collecting and verifying information.
- Medical history and problem list. Relevant past conditions, procedures, family or social history, and active health problems documented for the care context. The list may not include every detail of a person’s lifetime history.
- Clinical notes. Documentation from visits and other care interactions, such as histories, assessments, progress notes, and discharge summaries. The note types available depend on the organization and service.
- Medication information. Medication lists, prescriptions, and medication-related documentation. Lists can be incomplete or outdated, so clinicians may need to reconcile them with the patient and other sources.
- Allergies and adverse reactions. Known or reported allergies and reactions that are relevant to care. A blank or incomplete field should not automatically be interpreted as confirmation that no allergy exists.
- Orders and referrals. Requests for medications, laboratory work, imaging, procedures, or consultation, along with their status and associated instructions where supported.
- Laboratory and diagnostic results. Results from tests and examinations, which may include reports, values, and related information. External results may arrive separately or require reconciliation.
- Imaging and other clinical reports. Radiology images or reports and other diagnostic documents, depending on the system’s capabilities and connections.
- Immunization records. Vaccination information documented by the practice or received from connected sources. Availability and completeness vary.
- Care plans, patient instructions, and supporting forms. Plans, instructions, consent forms, or other records used in a particular care process. The exact forms and how they are stored vary by organization.
Are these components required in every EHR?
No. An EHR is configured for an organization’s specialty, workflows, and applicable requirements. The kinds of information stored and how they appear can differ between primary care, a hospital, behavioral health, and other settings. Standards such as the United States Core Data for Interoperability describe health-data classes and elements for specified interoperability uses; they are not a universal checklist of ten documents for every patient chart.
Information may also be distributed across connected systems. For example, images may live in an imaging system while the EHR contains the report or a link. A portal view may show only selected information and is not necessarily the entire record maintained by the provider.
