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A hospital information system (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals.In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation, such as medical, administrative, financial, and legal issues and the corresponding processing of services.
An admission, discharge, and transfer (ADT) system is a backbone system for the structure of other types of business systems. An ADT system is one of four types of core business systems: ADT, financial, scheduling, and acuity (McGonigle, D., & Mastrain, K., 2012).
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
The application responding to, i.e., performing, a request for services (orders) or producing an observation.The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
The generic model used in the United States is the chronic care model, which holds that health care does not only involve change in the patient and that high-quality disease care counts the community, the health system, self-management support, delivery system design, decision support, and clinical information systems as important elements in ...
In addition encounter diagnoses, immunizations, referral reason and discharge instructions may be required based on context. Several tools for the development, testing, validation and implementation have been advanced to support CCD and C-CDA use in the second stage of meaningful use which has helped the standard mature in its capability to ...
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
A computer-based protocol system is a paradigm providing a set of tools which allow health care providers access to current guidelines which they can apply in practice. [1] Studies have shown that protocols can aid in optimising patient care. [2] There are two types of protocol systems: passive and active.
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