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  2. Health informatics - Wikipedia

    en.wikipedia.org/wiki/Health_informatics

    The system designed for that purposes was called EMIAS (United Medical Information and Analysis System) and presents an electronic health record (EHR) with the majority of other services set in the system that manages the flow of patients, contains outpatient card integrated in the system, and provides an opportunity to manage consolidated ...

  3. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    The health information systems literature has seen the EHR as a container holding information about the patient, and a tool for aggregating clinical data for secondary uses (billing, audit, etc.). However, other research traditions see the EHR as a contextualised artifact within a socio-technical system.

  4. SBAR - Wikipedia

    en.wikipedia.org/wiki/SBAR

    [1] [2] During this stage the patient's chart is ready and as much important medical-based information is provided to set up the assessment of data. [9] Examples of medical-based information include date and reason for admission, most recent vital signs and vital signs outside of normal parameters, current medications, allergies, and labs, code ...

  5. Clinical decision support system - Wikipedia

    en.wikipedia.org/wiki/Clinical_decision_support...

    2. **Patient Data Interface**: Integrates with electronic health records (EHR) systems to access patient demographics, medical history, test results, and current medications. 3. **Inference Engine**: Analyzes patient data and applies clinical rules to generate suggestions or alerts based on predefined algorithms. 4.

  6. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    It states, amongst other things, the statutory duty of medical personnel to document the treatment of the patient in either hard copy or within the electronic patient record (EPR). This documentation must happen in a timely manner and encompass each and every form of treatment the patient receives, as well as other necessary information, such ...

  7. Adoption of electronic medical records in U.S. hospitals

    en.wikipedia.org/wiki/Adoption_of_Electronic...

    [2] The JKL Healthcare System was one of the first successful implementers of EMR using the Epic System, and they became a model site for other healthcare systems. JKL Healthcare received the Davies Award in September 2004, which is the most prestigious award in the IT industry for its implementation of the most comprehensive EMR system in the ...

  8. Medication Administration Record - Wikipedia

    en.wikipedia.org/wiki/Medication_Administration...

    A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...

  9. Point of care - Wikipedia

    en.wikipedia.org/wiki/Point_of_care

    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]