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E-consult is a web-enabled system and process, where primary care clinicians and specialists are able to communicate, share clinical information and consult electronically to manage patient care. [2] It reduces the specialty referral and appointment process to just a few days, which increases the speed delivery for patient care services.
OSCAR McMaster is a web-based electronic medical record (EMR) system initially developed for academic primary care clinics. It has grown into a comprehensive EMR and billing system used by many doctor's offices and private medical clinics in Canada and other parts of the world.
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
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.
When ambulatory and inpatient care providers attest that they have achieved the first stage of meaningful use, they document that they have tested their capability to "exchange clinical information and patient summary record", which is a core objective of the program. [8]
A hospital information system (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals.In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation, such as medical, administrative, financial, and legal issues and the corresponding processing of services.
The terms EHR, electronic patient record (EPR) and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.
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