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The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
A simple flowchart representing a process for dealing with a non-functioning lamp.. A flowchart is a type of diagram that represents a workflow or process.A flowchart can also be defined as a diagrammatic representation of an algorithm, a step-by-step approach to solving a task.
Health information technology (HIT) is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, health data, and knowledge for communication and decision making". [8]
This TeleMed project aimed to expand the electronic communication between health service parties, and e-referrals were a part of this. [16] By 2004, forty-one percent of all referrals sent were electronic. Causing a "significant improvement in access to care, quality of care, efficiency and productivity of the health sector". [3] [12]
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
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The process is named in one word, a short sentence, or a phrase that is clearly to express its essence. [7] Data flow. Data flow (flow, dataflow) shows the transfer of information (sometimes also material) from one part of the system to another. The symbol of the flow is the arrow.