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Electronic Health Records in the Hospital


Overview

The information in this chapter will enable you to:

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Outline

The Need for Clinical Information Systems
The Complexity of Hospital Information Systems
Components of an Inpatient EHR System
Clinical Documentation
Computerized Physician Order Entry
Decision-Support Tools
Medication Management in Hospitals
Technology and Medication Ordering
Electronic Medication Administration Records (eMAR)
Results Reporting
Digital Images and the Electronic Health Record
Advantages of Electronic Results Reporting

 

Learning Outcomes

After completing this chapter, you will be able to:

  1. Explain the functions of an EHR in an acute care hospital.
  2. List the primary benefits of a hospital EHR.
  3. List the uses of clinical documentation in an inpatient setting.
  4. Discuss the advantages of computerized physician order entry (CPOE).
  5. Explain how decision-support tools improve the quality of patient care.
  6. Describe how CPOE and electronic medication administration records (eMAR) work together to reduce medication errors.
  7. Describe the advantages of electronic results reporting over traditional paper-based reporting systems.







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