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  2. Health Information Technology for Economic and Clinical ...

    en.wikipedia.org/wiki/Health_Information...

    Maintain an up-to-date problem list of current and active diagnoses. Maintain active medication list. Maintain active medication allergy list. Record and chart changes in vital signs. Record smoking status for patients 13 years old or older. Implement one clinical decision support rule. Report ambulatory quality measures to CMS or the States.

  3. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...

  4. openEHR - Wikipedia

    en.wikipedia.org/wiki/OpenEHR

    A central part of the openEHR specifications is the set of information models, known in openEHR as 'reference models'. [6] The models constitute the base information models for openEHR systems, and define the invariant semantics of the Electronic Health Record (EHR), EHR Extract, and Demographics model, as well as supporting data types, data structures, identifiers and useful design patterns.

  5. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.

  6. Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Clinical_Document_Architecture

    The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange.In November 2000, HL7 published Release 1.0.

  7. Clinical decision support system - Wikipedia

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

    For example, an electronic evidence-based medicine system may potentially consider a patient's symptoms, medical history, family history and genetics, as well as historical and geographical trends of disease occurrence, and published clinical data on therapeutic effectiveness when recommending a patient's course of treatment.