Clinical
Charting, order entry, decision support and care planning.
12 steps · 10 questions · 9 screens on this shelf
The screens on this shelf
Records
Patients
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Possible Duplicate Patients
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.
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Records
Clinical Documentation
A signed note is the legal record: it is never edited, only addended.
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Order Entry (CPOE)
Orders run through decision support before they are written. A contraindication stops the order unless it is overridden with a reason.
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Records
Care Planning
The plan, its goals and who is accountable. Goals carry a measure and a target.
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Records
Order Sets
Standing orders, so a chest-pain workup is one action rather than five.
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Decision Support Alerts
Every alert that fired, and whether it was accepted or overridden. A high override rate says the alerts are being ignored.
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Report
Clinical Quality
Documentation completeness, decision-support override rate and laboratory quality.
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Medication Reconciliation
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.
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Progress is kept in this browser only — it is not sent anywhere and nobody else can see it.