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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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Methods of Documentation II: POMR01:26

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The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
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Pulse rhythm

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Pulse rhythm refers to the pattern of pulsations within specific intervals, offering valuable insights into the regularity or irregularity of the heart's beats as observed through the pattern of pulsation within specific intervals. A regular pulse exhibits a consistent heart rate with uniform waveforms and pulsation force, variations of which can be classified as normal, weak, or bounding.
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Flow Sheet01:17

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Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
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Perfusion Electronic Record Documentation Using Epic Systems Software.

Jeffrey B Riley1, George A Justison1

  • 1Mayo Clinic, Rochester, Minnesota; and University of Colorado Hospital, Aurora, Colorado.

The Journal of Extra-Corporeal Technology
|February 3, 2016
PubMed
Summary
This summary is machine-generated.

This commentary highlights lessons from the University of Wisconsin

Keywords:
EMREpic softwareelectronic medical recordintegrated perfusion anesthesia patient recordperfusion electronic record

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Area of Science:

  • Anesthesiology and Health Informatics
  • Medical Informatics
  • Cardiopulmonary Bypass

Background:

  • The University of Wisconsin adopted the Epic anesthesia record.
  • This system integrates perfusion information.
  • It covers the cardiopulmonary bypass patient experience.

Purpose of the Study:

  • To comment on Steffens and Gunser's article.
  • To highlight current-day lessons.
  • To emphasize quality and safety principles.

Main Methods:

  • Review of the Wisconsin-Epic model.
  • Analysis of integrated anesthesia and perfusion records.

Main Results:

  • The Wisconsin-Epic model provides valuable quality and safety principles.
  • The integrated record offers current-day lessons for anesthesia and perfusion.

Conclusions:

  • The Wisconsin-Epic anesthesia-perfusion record serves as a model for quality and safety.
  • Lessons learned can benefit other institutions.