Section 10.2: Chart Navigation, Note Types, and Order Entry

10.2.1 The “Why”: From Linear Data to a Living Digital Document

In your retail practice, your interaction with patient data has been powerful but focused. A prescription is a self-contained packet of information: patient name, drug, sig, prescriber. A patient profile is a chronological list of dispenses. This information is largely static and linear. The EHR, however, is a different species of entity entirely. It is not a static file; it is a dynamic, multi-dimensional, constantly evolving digital representation of a human being’s journey through the healthcare system. It is a living document, updated in real-time by dozens of contributors—physicians, nurses, therapists, dietitians, and now, you.

Mastering chart navigation is not a clerical skill; it is a core clinical competency. Your ability to move through this complex data structure with speed, efficiency, and purpose is directly correlated with patient safety and the quality of your interventions. Inefficient navigation leads to missed information—a critical lab value overlooked, a nursing note about a new side effect unread, a specialist’s recommendation buried on page three of a consult. These are not benign oversights; they are the precursors to medication errors. A pharmacist who cannot quickly synthesize the data in the chart is like a detective who cannot properly search a crime scene for clues. You might find the obvious evidence, but the subtle, case-breaking details will remain hidden.

Conversely, a pharmacist who achieves true EHR fluency can construct a comprehensive mental model of a patient’s clinical status in minutes. They can anticipate problems before they occur, connect disparate data points into a coherent narrative, and communicate their findings with precision and authority. This section is designed to build that fluency. We will move beyond simply pointing out where the buttons are. We will teach you the underlying logic of the patient chart, the purpose behind its different components, and a systematic method for extracting the information that matters most to a medication expert. This is the foundational skill upon which all of your other clinical activities—from therapeutic monitoring to prospective order verification—will be built. It is the art of learning to read the patient’s story as it is being written, moment by moment.

10.2.2 The Art of Chart Navigation: A Pharmacist’s Guided Tour

While the specific layout and terminology differ between Epic, Cerner, and other platforms, the fundamental structure of a patient’s chart is remarkably consistent. They are all designed to present different types of data in dedicated workspaces. Your first task is to develop a mental map of this universal structure. We will explore the core “rooms” of the chart, what they contain, and why they are critical to your workflow.

Your North Star: The Patient Header (Storyboard)

Before you take a single step into the chart, you must orient yourself. The patient header (called the “Storyboard” in Epic) is a condensed, always-visible banner of the most vital patient information. It is your constant point of reference, designed to prevent the most catastrophic of errors: acting on the wrong patient’s chart. Your brain must be trained to perform a “header check” every single time you open a chart and before you take any action.

A visual representation of a typical EHR patient header.

Your Pharmacist Workflow: The 5-Point Header Check (3 Seconds)

1. Patient Name & DOB: Does this match the patient you intend to work on? (The #1 safety check).
2. Allergies: What are the critical allergies? Is the reaction type listed (e.g., anaphylaxis vs. rash)? This immediately frames your verification process.
3. Weight & Renal Function: What is the most recent weight? What is the estimated CrCl? These two numbers guide nearly all of your dosing decisions.
4. Location: Where is the patient? (ICU vs. Med-Surg floor). This provides crucial context about their acuity.
5. Code Status: Is the patient Full Code, DNR (Do Not Resuscitate), or DNI (Do Not Intubate)? This is vital information in an emergency.

The MAR: Your Primary Workspace

The Medication Administration Record (MAR) is the digital successor to the paper MARs you may have seen from nursing homes. However, it is infinitely more powerful and complex. While your PDS shows what was dispensed, the MAR shows what was administered—or just as importantly, what was not administered. It is the definitive record of the patient’s interaction with medications during their hospital stay. You will spend more time in this section of the chart than any other.

Masterclass Table: Retail Dispensing Profile vs. Hospital MAR

Feature	Retail Pharmacy Dispensing Profile	Inpatient Hospital MAR	Why This Is a Game-Changer for Pharmacists
Core Purpose	A legal and billing record of medications dispensed from one pharmacy.	A real-time clinical and legal record of every dose administered to a patient within the hospital.	You move from historical dispensing data to live, actionable administration data. You can see the immediate effects of your work.
Timing	Shows the date a prescription was filled.	Shows the exact time each dose is scheduled for and the exact time the nurse scanned and administered it, down to the minute.	This allows for precise pharmacokinetic monitoring. You can see that a vancomycin dose was given at 08:05 and a trough level was drawn at 07:45, allowing you to accurately interpret the lab value.
PRN (“As Needed”) Doses	You see that a patient filled a script for oxycodone 30 days ago. You have no idea how many they have actually taken.	You can see the patient received PRN morphine at 02:17, 06:35, and 08:40. You can see the documented pain score before and after each dose.	This is one of the most powerful tools you have. You can objectively assess pain control, opioid requirements, and the need for standing analgesics, transforming you from a dispenser to a pain management consultant.
Non-Administration	If a patient doesn’t pick up a refill, it’s an assumption of non-adherence, but you don’t know why.	The MAR documents every held or refused dose with a required reason. “Dose held, patient NPO for procedure.” “Dose refused, patient states it makes her nauseous.” “Dose held, blood pressure 85/50.”	This provides a direct window into patient tolerance, side effects, and acute clinical changes. A held dose of an antihypertensive is a critical clue that the patient is becoming hypotensive and requires immediate attention.
IV Medications	Not applicable.	The MAR provides a detailed view of all infusions: the drug, concentration, rate (e.g., mL/hr), and any titrations made by the nurse based on parameters you verify.	You are now directly managing the most critical and high-risk medications in the hospital. The MAR is your command center for monitoring vasopressors, anticoagulants, and electrolyte infusions.

Results and Flowsheets: The Objective Data Streams

If the MAR is what’s being done to the patient, the Results and Flowsheets sections are how the patient’s body is responding. This is where you access the objective data that confirms your therapies are working and, crucially, that they are not causing harm. Your skill in spotting trends in this data is a defining characteristic of a clinical pharmacist.

• Results: This is the home for discrete, point-in-time laboratory values (chemistry, hematology, microbiology, drug levels) and imaging reports. The most powerful feature here is the ability to trend data over time. Viewing a single creatinine of 1.5 mg/dL is moderately informative. Viewing a table that shows the creatinine has risen from 0.8 to 1.1 to 1.5 over three days is a powerful clinical signal that demands investigation and action.
• Flowsheets: This section is designed for tracking high-frequency data, often documented by nurses at the bedside. This includes vital signs (blood pressure, heart rate, temperature), pain scores, blood glucose readings from fingersticks, sedation scores (for ICU patients), and intake/output records. For a pharmacist, this is the command center for titratable therapies. You cannot safely manage an insulin drip without a real-time view of the glucose flowsheet, nor can you assess the efficacy of an antihypertensive without trending the blood pressure.

10.2.3 Deconstructing Note Types: Learning to Read the Narrative

The discrete data in the MAR and Results tabs tells you what is happening, but the notes tell you why. They contain the clinical reasoning, the diagnostic uncertainty, the patient’s subjective experience, and the care plan. Learning to quickly read and extract the relevant information from different types of notes is a crucial skill. You are not reading these notes like a novel; you are scanning them with a pharmacist’s eye, hunting for clues that impact medication therapy.

Masterclass Table: A Pharmacist’s Guide to Clinical Notes

Note Type	Purpose & Author	What a Pharmacist Is Hunting For	Clinical Pearl
History & Physical (H&P)	The foundational document for the admission, written by the admitting physician.	The “story” of why the patient is here. The official Problem List, Assessment, and initial Plan. Details of the home medication reconciliation. Social history (alcohol, tobacco use).	This note sets the stage for the entire admission. If the physician’s documented plan is to “diurese the patient,” you know to pay extremely close attention to their electrolytes and renal function.
Progress Note (SOAP format)	The daily update, written by the primary medical team. (Subjective, Objective, Assessment, Plan).	The daily Plan is your goldmine. “Plan: Continue vancomycin, awaiting cultures. Will consult cardiology for arrhythmia.” This tells you the team’s thinking and what to anticipate.	Read the plan first. It’s often the last section of the note. In 30 seconds, you can learn the medical team’s goals for the day and align your pharmacy plan accordingly.
Consult Note	An opinion and set of recommendations from a specialty service (e.g., Infectious Diseases, Cardiology, Nephrology).	Specific, high-level medication recommendations. “ID recommends broadening antibiotic coverage to include Zosyn.” “Nephrology recommends holding ACE inhibitor until AKI resolves.”	Consult recommendations are often the source of major medication changes. You should proactively read these notes and ensure the recommendations have been translated into actionable orders. Be the one to call the primary team and ask, “I see ID recommended adding Zosyn, would you like me to enter that order for you?”
Nursing Note	Real-time, shift-by-shift documentation from the bedside nurse.	The patient’s subjective experience. “Patient c/o nausea after receiving oral antibiotic.” “Patient appears more confused this morning.” “Patient’s family states he is not taking his medications at home.”	This is where you find the information that never makes it into a lab value. A nursing note about a new rash after starting an antibiotic is a critical piece of data that you might be the first to see. Always trust the nurse’s assessment.
Pharmacist Note	Your own documentation of your clinical activities and recommendations.	A clear, concise record of your contributions to patient care. Recommendations, pharmacokinetic calculations, patient counseling, and accepted/rejected interventions.	This is your professional footprint in the chart. A well-written note justifies your value and communicates your plan to the entire team. Use a standardized format (e.g., SOAP or TITRS – Title, Introduction, Text, Recommendation, Signature).

10.2.4 The Science of Safe Order Entry: From Thought to Action

After navigating the chart, synthesizing the data, and formulating a clinical plan, the final step is translating that plan into a safe and effective order. In the hospital, most medication orders are entered directly by providers through a system called Computerized Provider Order Entry (CPOE). Your role is to then verify these orders, ensuring they are safe, appropriate, and accurate before they are dispensed and administered. However, you will also frequently be the one entering orders yourself, either verbally from a provider (“Can you go ahead and order that potassium replacement for me?”) or as part of a pharmacy-driven protocol. Mastering the mechanics and safety principles of order entry is a non-negotiable, foundational skill.

The Anatomy of a Perfect Order

Every medication order, from a simple tablet to a complex infusion, is built from the same core components. As the final checkpoint, you are responsible for ensuring every single component is correct. This is the clinical evolution of the “five rights” you learned in pharmacy school.

• The Right Drug: This seems obvious, but is a major source of error. Look-alike/sound-alike errors are common in dropdown menus (e.g., selecting clonidine instead of Klonopin). You must also ensure the correct formulation is chosen (e.g., Metoprolol Tartrate vs. Succinate).
• The Right Dose: Is the dose appropriate for the indication? Is it correctly adjusted for the patient’s renal or hepatic function? Is the calculation weight-based, and is the correct weight being used?
• The Right Route: Is the formulation appropriate for the chosen route (e.g., you cannot give a non-sterile oral solution intravenously)? For IV meds, is it compatible with the patient’s other IV fluids?
• The Right Frequency: Is the frequency appropriate for the drug’s half-life and the patient’s clearance? Is a q24h drug for a patient on dialysis going to be cleared properly?
• The Right Indication (The Clinical “Why”): This is the most important check. Why is this drug being ordered? Does the indication align with the patient’s diagnosis? An order for an anticoagulant on a patient with no history of VTE or Afib is a major red flag that requires an immediate call.

Mastering Different Order Types

Your order entry skills will need to adapt to the different types of therapies used in the inpatient setting.

Order Type	Description	Pharmacist’s Critical Verification Checklist
Scheduled	A medication given at regular, scheduled intervals (e.g., Lisinopril 10 mg PO daily at 0900).	Is the dose and frequency correct for the patient’s organ function? Is the administration time appropriate (e.g., not scheduling a diuretic at bedtime)? Are there any therapeutic duplications with other scheduled meds?
PRN (As Needed)	A medication given only when a specific condition is met (e.g., for pain, nausea, constipation).	Is there a clear indication (“for pain,” “for nausea”)? Is there a minimum frequency to prevent overdose (“every 4 hours as needed”)? Is there a maximum daily dose specified for drugs like acetaminophen?
Titratable Infusion	A continuous IV drip where the rate is adjusted by the nurse to achieve a specific physiological goal (e.g., an insulin drip or a norepinephrine drip).	Is there a clear, objective goal (“Titrate to maintain MAP > 65 mmHg,” “Titrate to maintain blood glucose 120-180 mg/dL”)? Is the starting rate, titration increment (e.g., “increase by 2 mcg/min”), and maximum rate all clearly specified? Is the drug concentration standard for the institution?
Order Set	A pre-built collection of orders for a specific condition or procedure (e.g., a “Sepsis Order Set” or a “Post-Op Knee Replacement Order Set”).	Do not blindly trust the order set. You must review every single order within the set for appropriateness for your specific patient. Does the patient’s weight, allergies, or renal function require you to modify the default doses in the set? Are there any orders in the set that are contraindicated for this patient?