Unit 3: Components of the EHR Flashcards
Clinical Information system CIS
collects and stores medical, nursing, clinical, and therapy information that are all protected by HIPAA
This data is used to diagnose, make treatment decisions, monitor conditions, and manage overall care
Document Management System DMS
Captures and manages documents
Different from an EHR
Allows for retrieval from any location
Multiple users can simultaneously view images which cannot be searched, edited, or changed
Used by Health Information Management
Scanner, magnetic storage, and file server
Radiology Information System RIS
collects, stores, and provides information on radiological tests such as:
ultrasound, MRI, PET, X-Ray, CT
Also gives the technician imaging guidance
productivity reports
Laboratory Information System LIS
collects, store, and manages laboratory test results
Accessible from anywhere
Typically separate from the EHR
Blood chemistry, pathology, blood bank, virology
Prints labels
Records quality control activities
Can also contain various management and productivity features and reports
Nursing Information System NIS
Assists in the planning and monitoring of overall patient care
Documents patient care
May be specialized by area of the hospital
POC point of care and bedside charting
automatically submits charges to the financial system
Shorter stays for patients
Scheduling and management of the nurses
Pharmacy Information System
Assists with ordering, allocating, and administering medication with a focus on patient safety
Checks dosages, drug interactions, allergies, etc.
Can be used to identify patterns of abuse by patients or physicians
Cardiology Information System
collects, stores, and manages cardiology images
Such as EKGs, echos, cardiac catheterizations, and stress tests
Interdisciplinary Charting
Can be used by any health care professional to collect and store patient assessments, progress notes, and care plans.
This includes physicians, nurses, physical therapists, pharmacists, dietitians, etc.
Frequently paired with tablets for bedside documentation
Emergency Department System EDS
track patients, reord tests results and clinical information
Tracking patients from triage to discharge
Anesthesia Department System
Collects preoperative, operative, and postoperative anesthesia information
Risk factors, vital signs, types of anesthesia, anesthetic agents, dosage
Able to generate management reports
Patient Monitoring System
Automatically collect and store patient data from fetal monitoring, vital signs, oxygen saturation rates
Results can be monitored remotely and make notes
Clinical Decision Support CDS
Brain of the EHR tah processes drug orders
Medication error alerts, reference materials, abnormal lab values, trend analysis, health maintenance
Telehealth
Also known as telemedicine
Allows a physician to examine and treat a patient remotely
Video, telephone, computers, smart phones, or other wireless medical devices
Telehealth
Also known as telemedicine
Allows a physician to examine and treat a patient remotely
Video, telephone, computers, smart phones, or other wireless medical devices
Can help people in rural communities who don’t have direct access to typically urban specialists
Telesurgery
use of robotics to perform surgery
Virtual reality and robotics
Surgery on a patient in a different location
No legislation yet surrounding safety/privacy
