EHR › Care Delivery
Clinical
Charting, order entry, decision support and care planning.
In EHR → Care Delivery · 9 screens
RecordsPatientsOpenViewPossible Duplicate PatientsEvery patient whose name matches another record together with the date of birth or an email or phone. Open both to compare. Different people: choose Not a duplicate and say why (or say why when saving with Create anyway), and the pair leaves this list.OpenRecordsClinical DocumentationA signed note is the legal record: it is never edited, only addended.OpenViewOrder Entry (CPOE)Orders run through decision support before they are written. A contraindication stops the order unless it is overridden with a reason.OpenRecordsCare PlanningThe plan, its goals and who is accountable. Goals carry a measure and a target.OpenRecordsOrder SetsStanding orders, so a chest-pain workup is one action rather than five.OpenViewDecision Support AlertsEvery alert that fired, and whether it was accepted or overridden. A high override rate says the alerts are being ignored.OpenReportClinical QualityDocumentation completeness, decision-support override rate and laboratory quality.OpenViewMedication ReconciliationAt admission, transfer, discharge or a visit: what the patient takes at home, what is ordered here and what other systems sent, side by side, a decision for each, signed, and the medication list changed to match.Open
Columns, fields and actions
| Screen | Kind | What it is | Columns | Fields | Actions |
|---|---|---|---|---|---|
| Patients | List | 7 | 17 | 1 | |
| Possible Duplicate Patients | Read-only list | Every patient whose name matches another record together with the date of birth or an email or phone. Open both to compare. Different people: choose Not a duplicate and say why (or say why when saving with Create anyway), and the pair leaves this list. | 7 | 0 | 3 |
| Clinical Documentation | List | A signed note is the legal record: it is never edited, only addended. | 8 | 12 | 2 |
| Order Entry (CPOE) | Read-only list | Orders run through decision support before they are written. A contraindication stops the order unless it is overridden with a reason. | 9 | 0 | 3 |
| Care Planning | List | The plan, its goals and who is accountable. Goals carry a measure and a target. | 10 | 10 | 0 |
| Order Sets | List | Standing orders, so a chest-pain workup is one action rather than five. | 5 | 5 | 0 |
| Decision Support Alerts | Read-only list | Every alert that fired, and whether it was accepted or overridden. A high override rate says the alerts are being ignored. | 8 | 0 | 0 |
| Clinical Quality | Report | Documentation completeness, decision-support override rate and laboratory quality. | 0 | 0 | 0 |
| Medication Reconciliation | Read-only list | At admission, transfer, discharge or a visit: what the patient takes at home, what is ordered here and what other systems sent, side by side, a decision for each, signed, and the medication list changed to match. | 10 | 0 | 6 |