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Electronic Health
Records for Allied
Health Careers
Chapter 4
Electronic Health
Records in the
Hospital
McGraw-Hill
Copyright © 2009 by The McGraw-Hill Companies, Inc. All Rights Reserved.
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Learning Outcomes
After studying this chapter, you should be able to:
1. Explain the functions of an EHR in an acute care
hospital.
2. List the primary benefits of a hospital EHR.
3. List the uses of clinical documentation in an inpatient
setting.
4. Discuss the advantages of computerized physician order
entry (CPOE).
5. Explain how decision-support tools improve the quality of
patient care.
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Learning Outcomes
After studying this chapter, you should be able to:
5. Describe how CPOE and electronic medication
administration records (eMAR) work together to reduce
medication errors.
6. Describe the advantages of electronic results reporting
over traditional paper-based reporting systems.
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Key Terms
• adverse drug event (ADE)
• computerized physician
order entry (CPOE)
• electronic medication
administration record
(e-MAR)
• five rights
• medication administration
record (MAR)
• medication reconciliation
• order sets
• transition points
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The Need for Clinical Information Systems
• Factors responsible for increased use of EHRs
and clinical information systems in hospitals:
– medical errors
– amount of available medical information
– quality standards
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Complexity of Hospital Information Systems
• Physician offices typically maintain one clinical
information system.
• Hospitals have numerous clinical information
systems including laboratory systems, pharmacy
systems, radiology systems, and various others.
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Components of an Inpatient EHR
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Clinical documentation
Computerized physician order entry
Clinical decision support
Electronic prescribing and electronic medication
administration records
• Electronic results reporting
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Medication Management
• Medication errors are most frequent source of
preventable medical errors in hospital setting.
• medication administration record (MAR) = log
containing information about the order and
documentation of administration of medication to
patient
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Medication Management
• adverse drug event (ADE) = side effect or
complication from medication
• transition points = times when patients move
from one location to another
• medication reconciliation = comparing patient’s
list of medications at admission with medications
ordered during hospital stay; if different, must be
reconciled before any drug is administered
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Electronic Medication Administration
Record (eMAR)
• electronically track medication administration via
bar coding to verify compliance with the five
rights of medication administration:
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the right patient
the right medication
the right dose
the right time
the right route
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Results Reporting
• allows providers to receive and review laboratory
and imaging test results from within the EHR.
• Whenever laboratory, radiology, or other tests are
performed in the hospital, the ordering clinician is
notified when results are available; the test results
are automatically sent to the patient’s EHR
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Digital Images
• Digital images of radiology results are created and
stored in picture archiving and communication
systems (PACS)
• PACS transfers the data to EHRs giving
physicians access to results
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Advantages of Electronic Results
Reporting
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faster turnaround time
faster diagnosis and treatment
efficient consultations
faster medication administration
fewer duplicate tests
enhanced analysis
easier retrieval