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Ch5 Hlth Info Mngmt

Electronic Health Record Systems

process of identifying source of HR entries by handwritten signature, author's initials or an electronic signature authentication
software & hardware located at patient's bedside that encourages recording of info about patient care at or near time it is delivered bedside documentation systems
collects, organizes, & analyzes all institutional business & clinical data that have been summarized & aggregated for that purpose clinical data repository
specific procedures/protocols for medical professionals to follow for patients w/particular diagnosis/medical condition based on research clinical practice guidelines
scheme for grouping similar things in logical way, based on common aspects; vary in level of detail enabling users to capture lrg amounts of specific, or granulary, data classification system
term to describe patient record system that could be part of hospital info sys., medical info sys., or type of clinical info system. computer-based patient record
ethical/legal concept endorsed by health professionals to meet expectation of patients that their info, when provided to auth. user, will not be redisclosed/misused confidentiality
clinical data repositories are designed to deliver individual patient's info to care team through clinical workstations
central repository for all info about database functions as catalog for identifying nature of all data in a system data dictionary
rules that are applied to data to trigger an outcome i.e. create an alert in an EHR data-driven rules
agreed on means of transmitting data & connecting data communications equipment data interface standards
technical, physical, & procedural methods by which access to confidential info is controlled & managed data security
receive clinical data from transactions system & combine them with other organizational data from administrative & financial systems data warehouses
contains info; may be in a physical or virtual format document
electronic health care record
electronic health record
event engine
health care information
health informatics
information warehouses
data dictionary provides central resource for ensuring that standard definitions for ___ ___ & ___ are used throughout the system data elements & structures
typically product of standards development organization & is recognized by the American National Standards Institute formal data interface standards
data warehouses are also referred to as information warehouses
natural language processing
niche vendors
patient record
patient record system
primary patient record
registration admission
registration discharge
registration transfer
script-based systems
secondary patient record
text processing
Created by: lfrancois