Lecture Electronic health records for allied health careers: Chapter 4 - Susan Sanderson

Chapter 4 - Electronic health records in the hospital. After 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 HER, list the uses of clinical documentation in an inpatient setting,...

Copyright © 2009 by The McGraw­Hill Companies, Inc. All Rights Reserved McGraw­Hill

Chapter 4

Electronic Health Records in the

Hospital

Records for Allied Health Careers

Learning Outcomes

After studying this chapter, you should be able to:

1 Explain the functions of an EHR in an acute care hospital.

2 List the primary benefits of a hospital EHR.

3 List the uses of clinical documentation in an inpatient

setting.

4 Discuss the advantages of computerized physician order

entry (CPOE).

5 Explain how decision-support tools improve the quality of

patient care.

Learning Outcomes

After studying this chapter, you should be able to:

5 Describe how CPOE and electronic medication

administration records (eMAR) work together to reduce

medication errors.

6 Describe the advantages of electronic results reporting

over traditional paper-based reporting systems.

Key Terms

• adverse drug event (ADE)

• computerized physician

order entry (CPOE)

• electronic medication

administration record

(e-MAR)

• five rights

• medication administration record (MAR)

• medication reconciliation

• order sets

• transition points

The Need for Clinical Information Systems

• Factors responsible for increased use of EHRs

and clinical information systems in hospitals:

– medical errors

– amount of available medical information

– quality standards

Complexity of Hospital Information Systems

• Physician 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 EHR

• Clinical documentation

• Computerized physician order entry

• Clinical decision support

• Electronic prescribing and electronic medication

administration records

• Electronic results reporting

Medication Management

• Medication 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 patient

Medication Management

• adverse drug event (ADE) = side effect or

complication from medication

• transition points = times when patients move

from one location to another

• medication reconciliation = comparing patient’s

list of medications at admission with medications ordered during hospital stay; if different, must be

reconciled before any drug is administered

Record (eMAR)

• electronically track medication administration via

bar coding to verify compliance with the five

rights of medication administration:

– the right patient

– the right medication

– the right dose

– the right time

– the right route

Results Reporting

• allows 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 Images

• Digital 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 results

• faster turnaround time

• faster diagnosis and treatment

• efficient consultations

• faster medication administration

• fewer duplicate tests

• enhanced analysis

• easier retrieval