TOPIC 11 - January

7,2014
 To define the term EHR and EMR.

 To know what is HPIS

 To know its importance and applications.

 Discussthe 3 elements in key areas in

online methods.
 Medicationused in hospital setting may
be described simply in several steps:
Ordering
Verification
Dispensing
Administering
Monitoring
• - full
narrative entries or scanned
copies of notes.

• - deals with the record of diseases

and interventions to cure them.
- it includes elements of health care

maintenance and preventive care items

-to provide structure to physicians order
and to allow for the rendering of decision
support tools at the moment of ordering.
 1. ACCESSIBILITY-
• by using INTERNET- based application, patient
data is available anytime, any location without
the need for medical record rooms and clerks.

2. LEGIBILITY
By restricting the range of numeric value to
prevent “keying” errors, thus to minimize
medication errors.
 3. USEOF DISCRETE DATA.
 correlation of certain disease states with
the appropriate prescribing of classes of
medications.
 DIAGNOSES
• - used for clinical decision support and for
billing support purposes.

UTILIZATION AND PROCEDURES

- Used among health services researchers to
understand patterns of care.
( laboratory or radiology test)
 LABORATORYFINDINGS AND
OBSERVATIONS- vital signs, ecg findings

(LOINC)- Logical Observations Identifier

Names and Codes
 - A developed a system of structural data for
laboratory findings and other observations
 DRUG CODE
 has sought to create a universal standard
for transmitting medication information
(Rxnorm)
 IMPLEMENTATION OF EHR’s
 to provide real time decision support to
clinicians
this system was the first to use in rendering of
clinical data from different system thus giving
the physicians with clinical guidance in their
orders.
 IN PATIENT DRUG ORDERS

 OUTPATIENT DRUG ORDERS

 DECISION SUPPORT
To be continued…..

thank you!