TABLE 4-1 Comprehensive List of Health Care Data Sources and Reporting Requirements

Clinical Datasets

Other Data Sources for Patient Safety Information

Histories

Allergies

Immunizations

Social histories

Vital signs

Physical examination

  • Physicians’ notes

  • Nurses’ notes

Laboratory tests

Diagnostic tests

Radiology tests

Diagnoses

Medications

Procedures

Clinical documentation

Clinical measures for specific clinical conditions

Patient instructions

Dispositions

Health maintenance schedules

Policies and procedures

Human resources records

Materials management systems

Time and attendance records

Census records

Decision support alert logs

Coroners’ datasets

Claims attachments

Admissions data

Disease registries

Discharge data

Malpractice data

Patient complaints and reports of adverse events

Reports to professional boards

Trigger datasets (e.g., antidote drugs for adverse drug events)

Computerized physician order entry systems

Bar-code medication administration systems

Clinical trial data



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