Chapter 4

1. Electronic Health Records for Allied Health Careers Cover goes here when ready Chapter 4 Electronic Health Records in the Hospital

2. Learning Outcomes After studying this chapter, you should be able to: • Explain the functions of an EHR in an acute care hospital. • List the primary benefits of a hospital EHR. • List the uses of clinical documentation in an inpatient setting. • Discuss the advantages of computerized physician order entry (CPOE). • Explain how decision-support tools improve the quality of patient care.

3. Learning Outcomes After studying this chapter, you should be able to: • Describe how CPOE and electronic medication administration records (eMAR) work together to reduce medication errors. • Describe the advantages of electronic results reporting over traditional paper-based reporting systems.

4. adverse drug event (ADE) computerized physician order entry (CPOE) electronic medication administration record (e-MAR) five rights medication administration record (MAR) medication reconciliation order sets transition points Key Terms

5. The Need for Clinical Information Systems • Factors responsible for increased use of EHRs and clinical information systems in hospitals: • medical errors • amount of available medical information • quality standards

6. Complexity of Hospital Information Systems • Physician offices typically maintain one clinical information system. • Hospitals have numerous clinical information systems including laboratory systems, pharmacy systems, radiology systems, and various others.

7. Components of an Inpatient EHR • Clinical documentation • Computerized physician order entry • Clinical decision support • Electronic prescribing and electronic medication administration records • Electronic results reporting

8. Medication Management • Medication errors are most frequent source of preventable medical errors in hospital setting. • medication administration record (MAR) = log containing information about the order and documentation of administration of medication to patient

9. Medication Management • adverse drug event (ADE) = side effect or complication from medication • transition points = times when patients move from one location to another • medication reconciliation = comparing patient’s list of medications at admission with medications ordered during hospital stay; if different, must be reconciled before any drug is administered

10. Electronic Medication Administration Record (eMAR) • electronically track medication administration via bar coding to verify compliance with the five rights of medication administration: • the right patient • the right medication • the right dose • the right time • the right route

11. Results Reporting • allows providers to receive and review laboratory and imaging test results from within the EHR. • Whenever laboratory, radiology, or other tests are performed in the hospital, the ordering clinician is notified when results are available; the test results are automatically sent to the patient’s EHR

12. Digital Images • Digital images of radiology results are created and stored in picture archiving and communication systems (PACS) • PACS transfers the data to EHRs giving physicians access to results

13. Advantages of Electronic Results Reporting • faster turnaround time • faster diagnosis and treatment • efficient consultations • faster medication administration • fewer duplicate tests • enhanced analysis • easier retrieval