{"id":1485,"date":"2022-12-10T00:18:00","date_gmt":"2022-12-10T00:18:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=1485"},"modified":"2026-02-24T16:58:48","modified_gmt":"2026-02-25T00:58:48","slug":"the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr","title":{"rendered":"The Anatomy of a Chart: How to read and interpret an EHR"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#1_Client_Demographics\" >1. Client Demographics<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#2_Admission_Progress_Note\" >2. Admission Progress Note<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#3_Test_Result_Impressions\" >3. Test Result Impressions<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#4_Medication_Administration_Record\" >4. Medication Administration Record<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#5_Nursing_Assessment_Notes\" >5. Nursing Assessment Notes<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#6_Health_Care_Maintenance_HCM\" >6. Health Care Maintenance (HCM)<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\/#About_the_Author\" >About the Author<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>When you&#8217;re new to nursing, there are so many important details to keep track of, including patient charts, also known as electronic health records (EHRs). Get some advice on what information is vital to maintaining accurate and up-to-date patient records while on the job.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Navigating the electronic health record (EHR)<\/strong>, commonly known as the <strong>&#8220;chart,&#8221;<\/strong> can be challenging as you begin your <strong>nursing school<\/strong> and <strong>clinical journey<\/strong>. Once you log in, you may feel overwhelmed by the endless amount of information and tabs to access. You might find yourself asking, <em>&#8220;Where do I even begin?&#8221;<\/em> Don\u2019t worry\u2014this is normal and happens to everyone. So, let\u2019s review <strong>six key sections<\/strong> of the EHR that you can start with when <strong>researching your client for clinical.<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"362\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/patient-demographic-variation.png?w=1024\" alt=\"An illustration of patient demographic variations.\" class=\"wp-image-6404\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/patient-demographic-variation.png 1236w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/patient-demographic-variation.png?resize=300,106 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/patient-demographic-variation.png?resize=768,272 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/patient-demographic-variation.png?resize=1024,362 1024w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"1_Client_Demographics\"><\/span>1. Client Demographics<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Client demographic information<\/strong> is a simple place to begin your exploration of the EHR. This section typically includes the client\u2019s <strong>name, date of birth<\/strong>, and may also contain important details such as <strong>isolation status, code status, admission date, and allergies.<\/strong>&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"2_Admission_Progress_Note\"><\/span>2. Admission Progress Note<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">After reviewing the client\u2019s demographics, you should access the client\u2019s <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Standards_and_methods_of_documentation:_Nursing\">admission note<\/a><\/strong>, which is usually written by a <strong>healthcare provider<\/strong>, such as a <strong>doctor or nurse practitioner<\/strong>. This progress note provides a detailed description of <strong>why the client came to the hospital<\/strong> and includes comprehensive data regarding their <strong>first physical assessment, past medical history, family history, and social history.<\/strong> Keep your eye on the prize\u2014this note may answer the question of <em>&#8220;what will get your patient discharged?&#8221;<\/em> by outlining the <strong>provider\u2019s plan for the rest of the hospital stay.<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"3_Test_Result_Impressions\"><\/span>3. Test Result Impressions<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Depending on the healthcare provider\u2019s orders, clients often have <strong>blood (lab) work<\/strong> and <strong>diagnostic testing<\/strong> scheduled consistently throughout their hospital stay. Sometimes viewing these test results can be overwhelming and time-consuming; therefore, focus your investigation on the <strong>impression<\/strong> of these results. Usually, each test result contains a <strong>concise summary<\/strong> written by the clinician interpreting the findings, which can help you better understand your client\u2019s condition.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Most charts also include tools to examine <strong>data trends over time<\/strong>\u2014for example, you can check if a client\u2019s <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Complete_blood_count_(CBC)_-_Red_blood_cells_(RBC):_Nursing\">Red Blood Cell (RBC) count<\/a><\/strong> is increasing or continuing to fall.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image alignright size-large is-resized\"><img loading=\"lazy\" decoding=\"async\" height=\"1024\" width=\"648\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/nurse-inputting-demographic-data-about-a-patient.png?w=648\" alt=\"A nurse inputting demographic data about a patient in an electronic health record (EHR).\" class=\"wp-image-6401\" style=\"width:330px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/nurse-inputting-demographic-data-about-a-patient.png 1133w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/nurse-inputting-demographic-data-about-a-patient.png?resize=190,300 190w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/nurse-inputting-demographic-data-about-a-patient.png?resize=768,1213 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/nurse-inputting-demographic-data-about-a-patient.png?resize=648,1024 648w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2022\/12\/nurse-inputting-demographic-data-about-a-patient.png?resize=972,1536 972w\" sizes=\"auto, (max-width: 648px) 100vw, 648px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"4_Medication_Administration_Record\"><\/span>4. Medication Administration Record<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Medication_administration_-_Safety_principles:_Nursing_pharmacology\">Medication Administration Record (MAR)<\/a><\/strong> is another vital part of the chart that provides information about the client\u2019s <strong>past, current, and future medications<\/strong>. Although you might not be administering medications right away, the MAR can help you understand how medications <strong>impact your client\u2019s assessment findings and vital signs.<\/strong> If you have any questions, call the <strong>pharmacy<\/strong>\u2014a <strong>pharmacist<\/strong> can be your best resource for medication-related questions.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"5_Nursing_Assessment_Notes\"><\/span>5. Nursing Assessment Notes<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Nurses typically write assessment notes<\/strong> on every client once per shift, which means your assigned client can have dozens of notes to review. To better understand your client\u2019s condition, read the <strong>last few days or shifts\u2019 worth of nursing notes<\/strong> to compare <strong>baseline assessments<\/strong> and <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Vital_Signs_-_Temperature:_Nursing_skills\">vital sign data<\/a><\/strong> to your current findings.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"6_Health_Care_Maintenance_HCM\"><\/span>6. Health Care Maintenance (HCM)<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">While your patient is in the hospital, make sure their <strong>HCM is up-to-date<\/strong>. Often what they need is available while they are inpatient, such as <strong><a href=\"https:\/\/www.osmosis.org\/blog\/a-quick-history-of-vaccines-from-smallpox-to-covid\">vaccinations<\/a><\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Remember, everything you learn from a chart should be <strong>validated<\/strong>, often by the <strong>patient themselves<\/strong>, and it should guide you in providing the <strong>best possible care.<\/strong> Always make sure the <strong>provider\u2019s goals<\/strong> align with the <strong>patient\u2019s goals.<\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"About_the_Author\"><\/span>About the Author<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><a href=\"https:\/\/www.linkedin.com\/in\/paige-randall-phd-ms-rn-cne-695b86b7\/\">Paige Randall MS, RN, CEN, CNE<\/a>,<\/strong> Script Writer and Editor<\/p>\n\n\n\n<figure class=\"wp-block-image size-full is-resized\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"498\" height=\"178\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-09T182315.478.png\" alt=\"Osmosis sign up ad\" class=\"wp-image-1487\" style=\"width:615px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-09T182315.478.png 498w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-09T182315.478.png?resize=300,107 300w\" sizes=\"auto, (max-width: 498px) 100vw, 498px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more <strong>NCLEX<\/strong>\u00ae-style practice questions? Try <strong>Osmosis from Elsevier<\/strong> today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>\u00a0and find out why millions of current and future <strong>clinicians and caregivers love learning by Osmosis<\/strong>.<\/em><a href=\"https:\/\/www.osmosis.org\/plans\/rn?source_cta=navbar\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Learn about the six essential sections of the electronic health record to review for comprehensive patient care during nursing clinical rotations and beyond.<\/p>\n","protected":false},"author":199,"featured_media":1486,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[10,21,867,32],"tags":[936,935,937,933,934,816,245,932,149,938],"class_list":["post-1485","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-clinical-skills","category-guides","category-lpn","category-nursing","tag-clinical-documentation","tag-ehr","tag-electronic-health-records","tag-healthcare-maintenance","tag-medication-administration","tag-nursing-clinicals","tag-nursing-education","tag-nursing-notes","tag-patient-care","tag-patient-charts"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>The Anatomy of a Chart: How to read and interpret an EHR - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The Anatomy of a Chart: How to read and interpret an EHR - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Learn about the six essential sections of the electronic health record to review for comprehensive patient care during nursing clinical rotations and beyond.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2022-12-10T00:18:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-02-25T00:58:48+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/54.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Paige Randall, PhD, MS, RN, CNE\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\"},\"author\":{\"name\":\"Paige Randall, PhD, MS, RN, CNE\",\"@id\":\"https:\/\/www.osmosis.org\/blog\/#\/schema\/person\/60dff72c4ea214c2d708f2ecd9029ee2\"},\"headline\":\"The Anatomy of a Chart: How to read and interpret an EHR\",\"datePublished\":\"2022-12-10T00:18:00+00:00\",\"dateModified\":\"2026-02-25T00:58:48+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\"},\"wordCount\":624,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/#organization\"},\"image\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/54.webp\",\"keywords\":[\"clinical documentation\",\"EHR\",\"electronic health records\",\"healthcare maintenance\",\"medication administration\",\"nursing clinicals\",\"nursing education\",\"nursing notes\",\"patient care\",\"patient charts\"],\"articleSection\":[\"Clinical Skills\",\"Guides\",\"LPN (Licensed Practical Nursing)\",\"Registered Nursing (RN)\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\",\"url\":\"https:\/\/www.osmosis.org\/blog\/the-anatomy-of-a-chart-how-to-read-and-interpret-an-ehr\",\"name\":\"The Anatomy of a Chart: How to read and interpret an EHR - 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