This page addresses follow-up questions and additional information pertinent to our webinar
Medical Terminology for Release of Information Professionals.
** The information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q:  What’s the difference between medication orders and the Medication Administration Record (MAR)?

A:  While both documents provide information about a patient’s medications, they serve different purposes. Medication orders tell us what the provider prescribed or ordered, while the MAR documents what happened with the administration of those medications, including whether they were given, held, or refused. For example, a provider may order a medication, but that doesn’t necessarily mean the patient received it.

For ROI professionals, this is an important distinction. If a request is asking for medications that were administered during a hospitalization, the MAR is generally going to provide that information, while the medication orders tell us what was prescribed.

Depending on the scope of the request, one or both documents may be relevant.

Q:  What if I can’t find a document because it’s called something different in our EHR?

A:  This is actually pretty common. Document names and how they’re organized can vary quite a bit between healthcare organizations and electronic health record systems. For example, what one organization calls a consultation report might be labeled as a consult note, specialty consultation, or specialist evaluation somewhere else. My recommendation is to focus on the purpose of the document and the type of information it should contain, rather than relying only on the document title.

It can also be helpful to look at the provider’s specialty, the encounter type, and the date of service to narrow down your search. And if you’re still having trouble locating something, don’t hesitate to reach out to someone familiar with your organization’s EHR or documentation workflows.

The more familiar you become with how records are organized in your own system, the easier it becomes to recognize and locate what you need.

Q:  I’m new to ROI. What’s the best way to get more comfortable reading and navigating medical records?

A:  I think one of the best places to start is by becoming familiar with the documents you encounter most often. Focus on understanding what each document is used for, the type of information it typically contains, and where it’s located in your organization’s EHR. As you’re reviewing records, pay attention to the terminology and abbreviations that come up frequently. You’ll probably find that many of the same terms appear over and over again.

MedlinePlus is a great free resource available through the National Library of Medine to look up unfamiliar medical terminology.

Most importantly, give yourself time to build that familiarity. The more you work with medical records, the more comfortable you’ll become recognizing different documents and understanding how they’re organized.

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