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A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow.
Uses templates to simplify workflow; Provides 24-hour, 7-day-a-week access to beneficiary EMR (assuming the network is working) Eliminates health record legibility issues; Enables population health and wellness reporting; Provides clinical functionality used in support of deployed service members, ensuring a "train as we fight" approach
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]
cTAKES ("clinical Text Analysis Knowledge Extraction Software") is a natural language processing system for extracting information from electronic medical record clinical free-text, an Apache top level project (TLP) since 2013, developed by the Mayo Clinic and others. It is available under the Apache license. [55]
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care.
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