Y khoa, y dược - Chapter 4: Electronic health records in the hospital

Chapter 4Electronic Health Records in the HospitalElectronic Health Records for Allied Health CareersCover goes here when readyLearning OutcomesAfter studying this chapter, you should be able to:Explain the functions of an EHR in an acute care hospital.List the primary benefits of a hospital EHR.List the uses of clinical documentation in an inpatient setting.Discuss the advantages of computerized physician order entry (CPOE).Explain how decision-support tools improve the quality of patient care.Learning OutcomesAfter studying this chapter, you should be able to:Describe how CPOE and electronic medication administration records (eMAR) work together to reduce medication errors.Describe the advantages of electronic results reporting over traditional paper-based reporting systems.Key Termsadverse drug event (ADE)computerized physician order entry (CPOE)electronic medication administration record (e-MAR)five rightsmedication administration record (MAR)medication reconciliationorder setstransition pointsThe Need for Clinical Information SystemsFactors responsible for increased use of EHRs and clinical information systems in hospitals:medical errorsamount of available medical informationquality standardsComplexity of Hospital Information SystemsPhysician offices typically maintain one clinical information system. Hospitals have numerous clinical information systems including laboratory systems, pharmacy systems, radiology systems, and various others.Components of an Inpatient EHRClinical documentationComputerized physician order entryClinical decision supportElectronic prescribing and electronic medication administration recordsElectronic results reportingMedication ManagementMedication errors are most frequent source of preventable medical errors in hospital setting.medication administration record (MAR) = log containing information about the order and documentation of administration of medication to patientMedication Managementadverse drug event (ADE) = side effect or complication from medicationtransition points = times when patients move from one location to anothermedication reconciliation = comparing patient’s list of medications at admission with medications ordered during hospital stay; if different, must be reconciled before any drug is administered9Electronic Medication Administration Record (eMAR)electronically track medication administration via bar coding to verify compliance with the five rights of medication administration:the right patientthe right medicationthe right dosethe right timethe right routeResults Reportingallows providers to receive and review laboratory and imaging test results from within the EHR. Whenever laboratory, radiology, or other tests are performed in the hospital, the ordering clinician is notified when results are available; the test results are automatically sent to the patient’s EHR Digital ImagesDigital images of radiology results are created and stored in picture archiving and communication systems (PACS)PACS transfers the data to EHRs giving physicians access to results12Advantages of Electronic Results Reportingfaster turnaround timefaster diagnosis and treatmentefficient consultationsfaster medication administrationfewer duplicate testsenhanced analysiseasier retrieval