The Clinician Visit

The provider will review the clinical information that has been obtained through the check-in and triage process. In most settings, this information will be used to create or update information in what is usually referred to as the health summary, face sheet, or another similar name that typically exists as a distinct container of the electronic health record. It contains patient-specific health information that may be stored as unstructured data, structured data, or codified structured data. For the purposes of this discussion, unstructured data typically means free text that is not supported by a specific designated field. An example of this might be paragraphs of text entered into a very general category such as “History ...

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