| EMR Checklist | |||||||||||||
| This document is copyrighted Jan.1, 2000, all rights reserved by the Emergency Matrix. | |||||||||||||
| Systems Interfaces | |||||||||||||
| Registration | |||||||||||||
| Order | |||||||||||||
| Results | |||||||||||||
| Note: When ascertaining a systems interface capablility, realize that most all professional software products have the capability to interface with other | |||||||||||||
| software systems. The limiting factor is the "right-of-way" fee charged by certain software vendors. This fee is often an exorbinant fee ranging anywhere | |||||||||||||
| from $1,000-$35,000 for access to the software source code so a interface may be written. Often this restrictive fee is the method in which | |||||||||||||
| certain software vendors try to monopolize an institutions business, by making it cost prohibitive to bring in additional software products, even if they themselves | |||||||||||||
| don't have a product that fits the specific needs they are their client is trying to fill. This tactic compliments the other tactic that certain large software vendors | |||||||||||||
| utilize when they promise a client a product that doesn't exist, hasn't been field tested, or may even be inferior to other vendors products. | |||||||||||||
| With the development of XML technology, this issue may become a mute point. | |||||||||||||
| Nursing Module | |||||||||||||
| Triage Input | |||||||||||||
| Allergies/immunizations | |||||||||||||
| Vital signs input | |||||||||||||
| Intake and output | |||||||||||||
| Medications | |||||||||||||
| IV Therapy | |||||||||||||
| Nursing Procedures | |||||||||||||
| Nursing Notes | |||||||||||||
| Nursing Assessment | |||||||||||||
| Nursing History | |||||||||||||
| Clinical Pathways | |||||||||||||
| Nursing Charges | |||||||||||||
| Nursing Supplies | |||||||||||||
| Data exchange with Physicians record is desired | |||||||||||||
| Data Reports | |||||||||||||
| Patient tracking | |||||||||||||
| QA data reports | |||||||||||||
| Point and Click Data Input | |||||||||||||
| Voice Input Capabilities | |||||||||||||
| PreHospital Data input | |||||||||||||
| Note: When assessing the functionality of a nursing electronic medical software system it is necessary to identify that the system | |||||||||||||
| enables an infinite number of assessment inputs. These inputs that include input/output, vital signs, neuro checks, and treatment modalities, must also | |||||||||||||
| be time/date stamped, as well as identify the person whom provided the input. | |||||||||||||
| Physician Module | |||||||||||||
| Point and click H & P | |||||||||||||
| Voice input capable | |||||||||||||
| Order Entry | |||||||||||||
| Records Archive | |||||||||||||
| Laboratory Input and Results | |||||||||||||
| Radiology Input and Results | |||||||||||||
| Extensive Procedural Listing | |||||||||||||
| Specific procedural data input | |||||||||||||
| Point and click data entry | |||||||||||||
| HCFA compliant | |||||||||||||
| Intuitive interface that prompts user for compliance items | |||||||||||||
| EKG input and results | |||||||||||||
| Treatment documentation | |||||||||||||
| Discharge Instructions in English and Spanish | |||||||||||||
| Discharge Instruction modification for specific user templates | |||||||||||||
| Electronic Prescriptions | |||||||||||||
| Capable of user prescription templates | |||||||||||||
| Capable user specified records templates | |||||||||||||
| Multiple Chief complaints | |||||||||||||
| Multiple Diagnosis | |||||||||||||
| Re-evaluation notes | |||||||||||||
| PATH compliant notes for teaching facilities | |||||||||||||
| Physician Assistant advisoring notes | |||||||||||||
| Referal physician demographic data | |||||||||||||
| Work release notes | |||||||||||||
| PALS Drug database point and click | |||||||||||||
| ACLS Drug database poInt and click | |||||||||||||
| Data exchange with Nurses notes if desired | |||||||||||||
| End of shift log | |||||||||||||
| Security Items | |||||||||||||
| User tracking log | |||||||||||||
| Auto log off capable | |||||||||||||
| password protected entry | |||||||||||||
| Work station data input tracking log | |||||||||||||
| Resident printing lock out | |||||||||||||
| P.A. printing lockout | |||||||||||||
| Individual User security profiling | |||||||||||||
| Multiple clearance levels | |||||||||||||
| End of shift log off | |||||||||||||
| Archive tracking | |||||||||||||
| Reporting | |||||||||||||
| End of shift log | |||||||||||||
| acuity logs | |||||||||||||
| admission logs | |||||||||||||
| physician summaries | |||||||||||||
| clinical pathway logs | |||||||||||||
| death logs | |||||||||||||
| hour logs | |||||||||||||
| R.N. supplies | |||||||||||||
| trauma activation logs | |||||||||||||
| call back logs | |||||||||||||
| tetnus logs | |||||||||||||
| infectious disease logs | |||||||||||||
| Patient discharge status logs | |||||||||||||
| AMA logs | |||||||||||||
| AWOL logs | |||||||||||||
| shift volume reporting | |||||||||||||
| RETURN | |||||||||||||