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Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care.
In medicine, patient compliance (also adherence, capacitance) describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self care , self-directed exercises, or therapy sessions.
The International Patient Safety Goals (IPSG) were developed in 2006 by the Joint Commission International (JCI). The goals were adapted from the JCAHO's National Patient Safety Goals. [1] Compliance with IPSG has been monitored in JCI-accredited hospitals since January 2006. [1]
The primary patient record is the record that is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions. The secondary patient record is a record that is derived from the primary record and contains selected data elements to aid non clinical ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
The National Patient Safety Goals is a quality and patient safety improvement program established by the Joint Commission in 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
The doctor–patient relationship is one factor in determining the patient's compliance with medical advice. [3] Patients adhere more closely to medical advice when the healthcare provider is friendly, doesn't interrupt the patient, or has good verbal communication skills. [ 4 ]
Auxiliary labels can commonly be misinterpreted, especially when multi-step or multi-part instructions are present on one label. [5] Misinterpretation of auxiliary labels can occur when patients are unable to understand the wording of the label, and thus assume an instruction based on the pictogram or color of the label. [5]