Cardiac Catheterization Lab
A procedural area where MAR auto-documentation is typically not used.

Charge Capture
The process of identifying and recording billable services from clinical documentation.

Charge Sheet (Misconception)
The incorrect assumption that the MAR alone functions as a billing document.

Claims
Formal billing submissions to payers requiring complete documentation support.

Clean MAR
A MAR showing no activity; not proof that no services occurred.

Clinical Context
The explanation of why a medication was administered, found in clinical notes.

Clinical Documentation
Records created by providers and nurses describing patient care and decisions.

Clinical Instrument
A tool designed for patient care (e.g., MAR), not financial reporting.

Clinical Notes
Narrative documentation explaining reasoning, response, and outcomes.

Clinical Outcomes
Patient results that medication safety systems aim to improve.

Clinical Workflow
The sequence of care delivery activities supported by the EHR.

Clinical Workflow Efficiency
Optimization of care delivery, often prioritized over billing completeness.

Code Blue
A cardiac arrest event where documentation is often manual or fragmented.

Coder’s Dilemma
The conflict between clinical documentation design and billing requirements.

Coders Mindset
An approach focused on corroboration, compliance, and audit defensibility.

Compliance
Adherence to regulatory, payer, and audit standards.

Compliance Risk
Exposure created when documentation does not support billed services.

Corroboration
Confirming a service across MAR, orders, notes, and flowsheets.

Critical Dataset
Viewing the MAR as structured data requiring interpretation—not proof.

Cross-Verification
Validating MAR data against other documentation sources.