Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:Analyzing Findings - 1 Part 1: Giving Structure to the Data 8
Slide notes:Once the data is gathered, it needs to be given some structure. In medical practice, physicians use a highly structured methodology of arranging information that has been used for generations, called the history and physical , or H&P. Clinical information systems and EHRs may be set up to support a template structure for clinicians to use with their data collection and entry. These templates can be set up not only for history and physicals but also for assessments, clinical notes, and treatment plans. 8