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Example. A practitioner typically asks questions to obtain the following information about the patient: Identification and demographics: name, age, height, weight.; The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
Typical data types which are often found within a CDR include: clinical laboratory test results, patient demographics, pharmacy information, radiology reports and images, pathology reports, hospital admission, discharge and transfer dates, ICD-9 codes, discharge summaries, and progress notes. [1]
Sample view of an electronic health record. An electronic health record (EHR) 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.
In computing, an enterprise[-wide] master patient index is a form of customer data integration (CDI) specific to the healthcare industry.Healthcare organizations and groups use EMPI to identify, match, merge, de-duplicate, and cleanse patient records to create a master index that may be used to obtain a complete and single view of a patient.
The sample population contained females within the age range of 25–42, employed as nurses, from 14 U.S. States. [5] Data collected included the brand of pill and length of use. [5] Over time, the study expanded to include information on basic practices and measurements of health, such as exercise practices and food intake. [5]
PICOT formatted questions address the patient population (P), issue of interest or intervention (I), comparison group (C), outcome (O), and time frame (T). Asking questions in this format assists in generating a search that produces the most relevant, quality information related to a topic, while also decreasing the amount of time needed to produce these search results.
Health data are classified as either structured or unstructured. Structured health data is standardized and easily transferable between health information systems. [4] For example, a patient's name, date of birth, or a blood-test result can be recorded in a structured data format.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]