EPIC MAR Vocabulary
This is not a comprehensive list and is regularly updated.
Administration
The act of giving a medication to a patient; billing is triggered at this stage in Epic.
Administration Instructions
Detailed directions attached to an order that may contain rate changes not clearly reflected on the MAR.
Analytical Mindset
A coder’s approach that prioritizes verification, skepticism, and defensibility over speed.
Audit Risk
The risk that a billed charge cannot be supported during an audit due to documentation gaps.
Auto-Documentation
Real-time documentation transmitted automatically from devices (e.g., smart pumps) to the EHR.
Auto-Programming
Automatic population of pump settings from the EHR to the IV pump.
Automated Documentation
System-generated charting intended to reduce manual entry but not guaranteed to capture all billable details.
Bidirectional IV Smart Pump Interoperability
Two-way communication between IV pumps and the EHR enabling auto-programming and auto-documentation.
Billable Activity
Any service or medication administration eligible for reimbursement when properly documented.
Billing Code
A code representing a billable service derived from clinical documentation.
Billing Convenience (False Priority)
Designing workflows for ease of billing rather than accuracy and compliance.
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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.
Dedicated Medication Safety Integration Nurse
Role overseeing safe implementation of medication technologies.
Defensible Charge
A charge supported by consistent documentation across all sources.
Dialysis
A procedural area where MAR automation may not apply.
Discrete Data
Structured, time-stamped data stored in flowsheets.
Disconnect (Clinical vs Financial)
Mismatch between MAR design intent and billing use.
DocumentReference (FHIR)
FHIR resource representing clinical notes as a separate data source.
Electronic Health Record (EHR)
Digital version of a patient medical record
Emergency Transport
Patient transfers where automated MAR documentation is not used.
Electrical Medical Record (EMR)
Much like the EHR differing by typically limited to one practice.
Endoscopy
Procedural area with limited MAR automation.
Epic
An EHR platform where billing is often triggered upon administration.
FHIR (Fast Healthcare Interoperability Resources)
Standard defining how healthcare data is structured and exchanged.
Financial Consequences
Revenue or compliance impact of documentation actions.
Financial Integrity
Accuracy and defensibility of billing practices.
Flowsheets
Epic data structures for recording discrete clinical measurements.
Foundational Data
Original documentation (orders, notes) required to justify charges.
Fully Autonomous Coding
Epic-supported automation that still flags cases for manual review.
Gravity Infusion
Manual fluid administration often undocumented on the MAR.
High-Acuity Situations
Emergent scenarios where auto-documentation is often bypassed.
High-Cost Drug
Medications requiring strong documentation support due to audit risk.
High-Risk Scenarios
Situations prone to documentation gaps and billing errors.
Indefensible Charge
A billed service lacking sufficient documentation support.
Interoperability
The ability of systems and devices to exchange data accurately.
Interventional Radiology
Procedural area where MAR may not reflect all services.
IV Smart Pump
Infusion device integrated with the EHR for safety and efficiency.
IVIG (Intravenous Immunoglobulin)
A titratable, high-cost infusion requiring detailed documentation.
Manual Documentation
Charting performed when automation is unavailable or inappropriate.
MAR (Medication Administration Record)
A clinical record of medication administration actions—not a billing record.
Medication Errors
Errors safety systems aim to reduce through automation.
Medication Process
Order → preparation → administration → documentation.
Missed Entries
Undocumented services that result in revenue loss or compliance risk
Narrative Documentation
Free-text clinical notes explaining patient condition and response.
Nursing Notes
Clinical documentation often required to validate MAR activity.
Orders
Provider-authorized instructions initiating medication administration.
Original Order
The foundational intent that must align with billed services.
Patient Chart
The complete collection of clinical documentation sources.
Patient Record
All stored clinical and administrative data for a patient.
Patient Safety
Primary design driver of MAR functionality.
Perioperative Areas
Surgical environments where MAR automation is limited.
Pitfalls
Common documentation failures leading to billing errors.
Pressure Bags
Emergency infusion tools often lacking MAR documentation.
Procedural Areas
Departments where billable activity is frequently documented outside MAR.
Rapid Fluid Resuscitation
Urgent fluid delivery requiring manual documentation.
Rapid Response Team
Emergency care group where documentation is often fragmented.
Rate Adjustments
Changes to infusion rates often missing from the MAR view.
Red Flag
Indicator that documentation is incomplete or misleading.
Remote Patient Monitoring (RPM)
Example of flowsheet-based discrete data capture.
Revenue Cycle
End-to-end process converting care into reimbursement.
Revenue Loss
Financial impact of missed or unsupported charges.
Risk Mitigation
Strategies to reduce audit and compliance exposure.
Scope of Service
The full extent of care provided that must be reconstructed for billing.
Skeptical Review
Assuming documentation may be incomplete until verified.
Smart Pump
Infusion device supporting medication safety integration.
Standalone Source of Truth (Myth)
False belief that one documentation source is sufficient.
Technical Playbooks
Epic documentation describing system data flow.
Time-Stamped Data
Chronological data critical for billing validation.
Titratable Infusion
Infusion requiring frequent rate changes and deeper review.
Trauma Resuscitation
High-acuity care with minimal automated documentation.
Verification
Confirming documentation accuracy before billing.
Wound Care Documentation
Example of flowsheet-based clinical data capture.