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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.
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 ...
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.
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.
Victoria has attempted to implement EHR across the state with its HealthSMART program, but it has cancelled the project due to unexpectedly high costs. [35] South Australia (SA) however is slightly more successful than Victoria in the implementation of an EHR. This may be because all public healthcare organisations in SA are centrally run.
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.
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A list of problems may be organized by priority or by organ system, with specific actions associated with each item on the problem list. Additional sections for "fluids, electrolytes, and nutrition" and "disposition" may be added near the end.
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