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The Committee on Improving the Patient Record, Division of Health Care
Services, Institute of Medicine, in a book titled “The Computer-Based
Patient Record” identified 12 attributes that comprehensive computer-based
patient records and record systems must possess.
EMRitus includes all 12 identified attributes, some of which are as follows:
- The CPR
contains a problem list that clearly delineates the patient’s clinical
problems and the current status of each
- The CPR
encourages and supports the systematic measurement and recording of
the patient’s health status and functional level to promote more precise
and routine assessment of the outcomes of patient care
- The CPR
states the logical basis for all diagnoses or conclusions as a means
of documenting the clinical rationale for decisions about the management
of the patient’s care
- The CPR
can be linked with other clinical records of a patient – from various
settings and time periods – to provide a longitudinal (i.e., lifelong)
record of events that may have influenced a person’s health.
- The CPR
is accessible for use in a timely way at any and all times authorized
by individuals involved in direct patient care.
- The CPR
can assist and, in some instances, guide the process of clinical problem
solving by providing clinicians with decision analysis tools, clinical
reminders, prognostic risk assessment, and other clinical aids.
- The CPR
supports structured data collection and stores information using a defined
vocabulary. It adequately supports direct data entry by practitioners.
- The CPR
can help individual practitioners and health care provider institutions
manage and evaluate the quality and costs of care
- The CPR
is sufficiently flexible and expandable to support not only today’s
basic information needs, but also the evolving needs of each clinical
specialty and subspecialty.
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