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welcome to the a EHR video training series presented by the information technology education department at UK healthcare this course is intended as initial a EHR training for residents this video is video number three in a series of four and is divided into a series of five chapters this first chapter will introduce you to the process of documenting a patient visit in a note in a EHR in this chapter we will discuss methods for documenting the HPI review of systems physical exam assessment and treatment plan among other topics every clinic has its own set of unique notes this video will discuss the basics should be included in most notes it is advisable for you to review the clinical summary document that is printed out and given to patients at the end of their visit in the clinic that you are working any information listed on this clinical summary document will need to be completed in your note before the patient leaves the clinic this way the patient will receive a full clinical summa