P.P.P.Paste "EHR Functional Descriptors"

熟透番薯

Capture Patient Demographics       
Capture demographic information that is reportable and trackable over time.       
Contact information including addresses and phone numbers, as well as key demographic information such as date of birth, sex, and other information should be stored for reporting purposes and the proper provision of care.

熟透番薯

Manage Problem List       
Create and maintain patient-specific problem lists.        
A problem list may include, but is not limited to: ?Chronic conditions, diagnoses, or symptoms ?Visit- or stay-specific conditions, diagnoses, or symptoms Problem lists must be managed over time, whether over the course of a visit or stay or the life of a patient, allowing documentation of history information and tracking the changing character of the problem and its priority. All pertinent dates, including date noted, dates of any changes in problem specification or prioritization, and date of resolution, should be stored. The entire problem history for any problem in the list should be viewable.

熟透番薯

Manage Medication List       
Create and maintain patient-specific medication lists.       
Medication lists must be managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates, should be stored. The entire medication history for any medication should be viewable. Medication lists should not be limited to medication orders recorded in the EHR, but should also include patient-reported medications.

熟透番薯

Manage Allergy List       
Create and maintain patient-specific allergies and reactions.       
Allergens should be uniquely identifiable whenever possible. Allergen lists must be managed over time. All pertinent dates, including patient-reported events, should be stored and the description of the patient allergy should be modifiable over time. The entire allergy history for any allergen should be viewable.

熟透番薯

Manage Other Summary Lists       
Create and maintain patient-specific summary lists not otherwise specified.        Problem, medication, and allergy lists are examples of summary lists.
The EHR should enable the creation and maintenance of other types of patient summary lists when appropriate for the patient or a particular care setting.

熟透番薯

Manage Patient History       
Capture, review, and manage medical, procedural, social, and family history including the capture of pertinent negative histories.       
Patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members should be captured. This data may take the form of a positive or a negative such as: "The patient/family member has had..." or "The patient/family member has not had..."

熟透番薯

Review chart summary       
Make available a chronological, filterable, comprehensive review of the patient's entire clinical history, subject to confidentiality constraints.        
A key feature of an electronic health record is its ability to present, summarize, filter, and facilitate searching through the large amounts of data collected during the provision of patient care. Much of this data is date or date-range specific and should be presented chronologically. Local confidentiality rules that prohibit certain users of the EHR from accessing certain patient information must be supported.

熟透番薯

Enable ordering of diagnostic tests       
Submit diagnostic test orders based on specific care provider input.       
For each orderable item, the appropriate detail and instructions must be available for the ordering care provider to complete. Orders for diagnostic tests should be transmitted to the correct destination for completion or generate appropriate requisitions for communication to the relevant resulting agencies.

熟透番薯

Enable placing of communication and other orders       
Submit communicative or administrative orders based on specific care provider input.       
The EHR should facilitate orders that are for the purposes of communication between care providers rather than the performance of diagnostic tests or the administration of medications.. Examples include orders to transfer a patient between units or to ambulate a patient. For each orderable item, the appropriate detail and instructions must be available for the ordering care provider to complete. Communication orders should be transmitted to the correct destination for completion.

熟透番薯

Enable use of order sets       
Provide order sets based on provider input or system prompt.       
Order sets allow a care provider to choose common orders for a particular disease state or circumstance according to best practice or other criteria for assembling the order set without having to generate each order individually. The EHR may recommend order sets in certain conditions or as the result of other clinical information being entered into the EHR. Or the order sets may simply be available for use by the ordering care provider.

熟透番薯

Enable ordering and tracking of referrals       
Enable the origination, documentation and tracking of referrals between care provider or care settings, including clinical guidelines and administrative details of the referral.       
The EHR should allow the documentation and tracking of a referral from one care provider to another, whether the referred to or referring providers are internal or external to the healthcare organization using the EHR. Guidelines for whether a particular referral for a particular patient is appropriate in a clinical context and with regard to administrative factors such as insurance should be provided to the care provider at the time the referral is created.