Activation:特定站点或区域开始使用新信息系统功能的时间。另请参阅:Go-Live,实施。
临时图表- 允许将静态,时间临床文档输入患者图表。只有那些
with privileges to perform ad-hoc charting can access the appropriate menu commands to launch a particular documentation tool.
Bar-coded Medication Administration (BCMA)- 闭环药物给药的完整过程。与BCMA相关的项目包括:患者腕带;扫描仪;条形码;和临床文档。医院的药物标有独特的酒吧代码。当患者处方药时,将药物输入信息系统。
当临床医生使用药物治疗时,他或她使用手持设备来扫描患者腕带和药物上的条形码。如果BPOC系统无法与系统中的订单相匹配,则会通过视觉警告提醒临床医生。该系统还将提醒临床医生的禁忌症。BCMA降低了风险,改善了患者护理。
BCMA– see: Bar-coded Medication Administration (BCMA).
Best Possible Medication History (BPMH)- 一个正式的过程,医疗保健提供者与患者,家庭和护理人员合作,以编译准确,全面的客户药物信息。BPMH是一个承认的要求,即护理和医生现在将在电子健康记录中完成;对于门诊和急诊室临床医生来说,它也是最佳实践。
BMDI- 请参阅:生物医学设备集成。
生物医学设备集成(BMDI)– A process that allows for information collected on external biomedical devices, such as vital sign monitors, to be sent to the electronic health record. A clinician will validate, within the electronic health record, that the information is accurate.
BPMH- 请参阅:最好的药物病史(BPMH)。
护理指南针——一个创新的、跨学科workflo摘要w solution that helps the collaborative care team organize, prioritize, and plan patient care by providing the right information at the right time. The solution includes real time order and result notification.
护理集– A set of commonly requested orders grouped together for ease of order entry.
Cerner标准– Content and workflows created by Cerner, based on experience and collaboration with experts (including previous and current clients) to form a set of best recommendations for new clients.
计算机提供商订单条目(CPOE)– The placement of orders into the computer system using either groups of orders (electronic clinical order sets) or single orders, by the provider or designated clinician. CPOE tools are implemented in conjunction with electronic clinical decision support to encourage best practice and evidence.
控件– The data elements about the patient that will cross encounters (medical history, allergies, procedure history, social history, family history).
Once entered into the patient’s electronic health record, the controls remain on the patient’s chart, and are validated and updated upon each healthcare encounter.
CPOE– See: Computerized Provider Order Entry (CPOE).
当前状态- 我们现在运作的医疗保健环境 - 纸质的混合状态和一些电子。另请参阅:未来状态。
离开过程——这个过程由一个组件在Cerner system used to guide and support an informative discharge of the patient. The depart process includes Educational Material (Healthwise) and follow-up information and referral information, and feeds information into the Clinical and Patient Summary.
Discharge Dashboard– A visual representation of what has been completed from the multi-disciplinary team in respect to a patient’s discharge. This information is fluid and updated throughout the patient’s episode of care.
离散任务测定(DTA)- 电子健康记录中的独特日期元素。
领域- 具有单独数据库的Cerner解决方案的环境。实时域的开发和完善中可以使用多个域。还有一个用于自定义岛屿健康需求的内容的构建域。beplay全站App
EHR- 请参阅:电子健康记录(EHR)。
电子健康记录(EHR)– The collective electronic medical records of a patient or a population of patients.
Electronic Medication Administration Record (eMAR)– The electronic documentation of the medications administered to a patient at a facility by a health care professional. Nurses document their administration of medications to the patient online using the electron Medication Administration Record. Typically, this tool displays doses of medication and their scheduled times. See also: MAR
Electronic Signature– An electronic means of indicating that an individual verifies the content.
Emar– see: Electronic Medication Administration Record (eMAR).
Encounter- 描述当患者在医疗保健系统中注册的特定实例(例如,医院,诊所,日托,家庭保健或其他任何获得服务的部门)。它是一种单一的患者互动,例如注册为住院患者的患者,患者注册为门诊病人。
遇到号码– An encounter-specific identifying number.
最终用户– Any person using the electronic health record, including physicians and hospital staff.
胎儿链接– Cerner solution displaying data sent from fetal monitoring devices, providing a graphical display of the relationship between uterine contractions and fetal heart rate, and alerting the clinician to out-of-reference-range data trends.
FirstNet– Cerner’s emergency medicine information system.
流程图– A spreadsheet of a selected patient’s clinical results for a certain time span. All types of results are arranged on a grid that is sorted by result categories on one axis, and by time increments or specific times on the other axis. Any result can be opened to view its creation history, status, and, when applicable, its comparison to normal values for its result type.
New results can be entered into the flowsheet by electronic capture (handheld devices at the bedside, for example), by direct charting, or by feeds from other systems. The data is refreshed automatically at user-defined intervals, or can be refreshed manually at any time.
未来状态- 我们采用/启动电子健康记录后,我们的医疗保健提供环境。另请参见:当前状态。
Go-Live- 特定站点或区域开始使用新信息系统功能的时间。另请参阅:激活,实施。
交互式视图(Iview)– Clinical documentation in a flow sheet, which allows for trending and comparison.
Interdisciplinary Plan of Care (IPOC)- 与特定客户需求有关的护理计划。每个IPOC都由目标,指标和干预措施组成。
IPOC– see: Interdisciplinary Plan of Care (IPOC).
iview- 请参阅:交互式视图(Iview)。
LightsOn– Industry-leading advanced electronic health record analytics solution provided by Cerner and designed to support decision making and provide transparency into the Cerner solutions. LightsOn is used to monitor System Performance and Stability, Provider Adoption and Efficiency, and Solution Build Best Practices.
Lighthouse Programs– Evidence-based tools embedded into clinical ordering and documentation through Cerner applications. The Lighthouse Programs are designed to drive clinical improvement in these key areas:
- 预防静脉血栓栓塞(VTE)。
- 预防败血症及其并发症。
- Prevention of pressure ulcers (PU).
- Prevention of hospital-acquired infections and improve infection control.
MAR- 请参阅:电子药物管理记录(EMAR)。
MAW- 请参阅:药物管理向导(MAW)。
Medication Administration Wizard (MAW)- 电子健康记录中的工具促进了闭环药物文档。MAW通过扫描过程(EMAR)验证患者和药物。
Medication Summary- EMAR的摘要页面显示了患者的药物,包括给定的最后剂量,服用的药物类型和停用药物。
千年页(MPAGE)- 它从其他文档中汇集了信息,以创建一种观点,该视图旨在为他们的工作中的不同学科和工作流提供信息(即“线管和排水管” mpage)。
模型系统- 我们使用的起始系统用作包含Cerner标准内容的起点。
MPage: See Millenium Page (MPage).
患者摘要(或SBAR)– A Millenium page (MPage) with a specific summary function (Situation/Background/Assessment/Recommendation), populated from IView and Power forms.
计划的州订单– Order sets that exist electronically in the Orders section of the electronic health record, waiting for nursing to decide to activate them.
PowerForms– One-time electronic documents that live in an AdHoc folder before they are completed, and Form Browser after they are completed.
Powerchart– The Cerner Millenium solution that is the clinician’s desktop solution for viewing, ordering and documenting the electronic health record for a patient.
强力计划- 任何提供商(例如,医师,护士从业者或助产士)可以订购的电子订单集。这是临床顺序集的电子替代。
Positive Patient Identification (PPID)– The use of all available sources, data elements, documentation and verbal testament to determine an individual’s identity. A minimum of two data elements is required for positive patient identification, and a minimum of three data elements will be used when they are available (i.e., name, date of birth, MRN and/or PHN and/or Encounter Number).
PPID– See: Positive Patient Identification (PPID).
问题列表- 所有以前的问题和长期诊断等的清单(即患者固有的所有状况,但不是当前访问的具体诊断)。
例如:患者患有糖尿病,但在这里进行阑尾切除术。诊断是阑尾炎,糖尿病进入患者的问题清单。问题可能是一个积极的问题,也可以是解决事物的历史。
Quick Glance Functionality– A tool that shows an overview of activities, such as medications due, patient
assessments and patient care, for the clinician’s group of patients. Shown in a bar graph format at the bottom of the Care Compass screen.
败血症灯塔计划– See: Lighthouse Programs.
SME- 参见:主题专家(SME)。
Subject Matter Expert (SME)– Within the IHealth initiative, these are Island Health direct clinical care staff and clinical support staff who have been participating in the development of the information system, and informing the design of the programming to work/match island health processes.
Surginet- Cerner Millenium解决方案,使手术部门可以安排,记录和运行有关手术病例的管理报告。
Task List (Activities and Interventions)– A list of tasks (requests) generated either from Providers’ orders or auto-generated by the system. This tool helps nursing staff organize their tasks, and move straight to the documentation attached to that task, from the list.
Workflow– The steps you take as you do your job and the order in which you do them (e.g., get my assignment, look through my charts, begin patient assessments, etc.).
