The retrospective review of the patient’s complete written record by an expert for the purpose of a specific analysis. For patient safety, to identify possible adverse events by reviewing the physician and nursing progress notes and careful examination for certain indicators.
A taxonomy that arranges or organizes like or related terms for easy retrieval (National Committee on Vital and Health Statistics, 2000).
Clinical data repository.
Clinical database optimized for storage and retrieval for information on individual patients and used to support patient care and daily operations (Shortliffe et al., 2001).
Clinical Document Architecture.
A document markup standard that specifies the structure and semantics of “clinical documents” for the purpose of exchange (Van Hentenryck, 2001).
A clinical area of interest that might be modeled for a clinical information system. (van Bemmel, 1997)
Clinical event monitor.
Rule-based programs that sit atop a clinical data repository, supporting real-time error prevention.
Clinical information systems.
The components of a health care information system designed to support the delivery of patient care, including order communications, results reporting, care planning, and clinical documentation (Shortliffe et al., 2001).
An event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention (U.S. Department of Veterans Affairs, 2002).
A numeric or alphanumeric representation assigned to a term so that it may be more readily processed (National Committee on Vital and Health Statistics, 2000).
Ability to compare similar data held in different computer systems. Comparability requires that the meaning of data is consistent when shared among different parties (National Committee on Vital and Health Statistics, 2000).
Computer detection rules.
Boolean combinations of medical events, for example, new medication orders and laboratory results outside certain limits that suggest an adverse drug event might be present.
Computerized physician order entry (CPOE).
Clinical systems that utilize data from pharmacy, laboratory, radiology, and patient monitoring systems to relay the physician’s or nurse practitioner’s diagnostic and therapeutic plans and alert the provider to any allergy or contraindication that the patient may have so that the order may be immediately revised