| 以病人为中心 |
|
|
|
|
|
|
|
|
|
|
|
|
| 门诊 |
Intake and Nurse assessment |
挂号/登记 |
记录 |
1.16 (访问患者人口学信息), 7.6 (记录出生日期), 7.9-12 (记录民族、性别、身高、成长曲线), 7.14 (记录医保类型), 7.25 (记录使用语言), 7.28 (记录种族), 7.34(记录吸烟状态),7.8(记录门诊情况encounter) |
|
挂号人员 |
x |
|
|
|
|
x |
|
|
测量记录生命体征 |
记录 |
7.40(记录生命体征 vital signs); 7.41(记录体重weight) |
|
医师助理、护士 |
x |
|
|
|
|
x |
|
|
用药回顾 |
回顾 |
1.10-12(访问药物过敏史、用药史、现用药列表mediation allergy history, medication history, active medication list ) |
|
医师助理、护士 |
|
|
|
x |
|
|
|
|
Handoff/移交 |
通知 |
2.2(临床摘要的接收确认acknowledge receipt of clinical summary), 19.5(临床摘要的传输transmit clinical summary), 12.13(接收来自其他机构的病人摘要记录receive patient summary allergy record from other providers) |
|
医师助理、护士、医师 |
|
|
x |
|
|
x |
|
医师评估 |
表单回顾 |
回顾 |
1.1-28 (访问医疗记录中的所有信息Access - all information in medical record)17.13 (回顾质控结果Review quality measure results |
|
医师 |
|
|
|
x |
|
|
|
|
询问病人 |
执行 |
|
|
医师助理、护士、医师 |
x |
|
|
|
|
x |
|
|
记录病史 |
记录/文档 |
7.1(每次encounter 记录病程记录Document a progress note for each encounter) |
|
|
|
|
|
|
|
x |
|
|
诊断和制定治疗计划 |
执行 |
|
|
医师 |
|
|
x |
|
|
x |
|
|
回顾先前的检验结果 |
|
17.1-2(回顾检验结果报告中所有信息review all information for a lab test report, clinical lab tests received with LOINC codes) |
|
|
|
|
|
|
|
x |
|
|
下达检验医嘱 |
医嘱 |
10.4(下达检验医嘱order lab study) |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
处方 |
医嘱 |
10.1(下达药嘱Order medication),10.5-7 (下达一般药嘱和新药嘱Order medication generic-, new), 19.6 (处方的传输transmit prescription) |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
转诊/转科 |
医嘱 |
10.10 (下达转科/转诊医嘱Order provider referral) |
|
医师 |
|
x |
|
|
|
x |
|
|
治疗 |
执行 |
|
|
医师、护士 |
|
|
|
|
|
|
|
|
患者咨询 |
执行 |
|
|
医师、护士 |
x |
|
|
|
|
x |
|
Check out/离开 |
Give out instructions |
记录 |
2.1(确认已接受患者教育Acknowledge education receipt |
|
医师助理、护士 |
x |
|
|
x |
|
x |
|
|
安排下次预约 |
Create |
15.1-2 (提醒患者下次随访、预防保健Remind patient per patient preference for follow-up, preventive care) |
|
挂号人员 |
|
|
|
|
|
|
| 急诊 |
高危病人到达急诊室 |
通知救护车 |
通知 |
12.13(收到来自其他机构的患者病历摘要Receive patient summary record from other providers), 2.2(确认接收Acknowledge receipt of clinical summary), 19.5(传输患者摘要信息Transmit clinical summary) |
|
护士 |
|
|
|
|
|
x |
|
|
测量、记录生命体征 |
记录 |
7.40(记录生命体征 vital signs); 7.41(记录体重weight) |
|
EMS医疗急救护理人员 |
x |
|
|
|
|
x |
|
|
Handoff |
记录 |
7.1(记录每个encounter的病程记录) |
|
护士 |
|
x |
|
|
|
x |
|
|
询问病人 |
执行 |
|
|
护士、医师 |
x |
|
|
|
|
x |
|
|
记录病史 |
记录/文档 |
7.1(每次encounter 记录病程记录Document a progress note for each encounter) |
|
医师 |
|
|
|
|
|
x |
|
低危的urgent care /Safety net care 到达急诊室 |
|
|
|
|
|
|
|
|
|
|
|
|
|
询问病人 |
执行 |
|
|
护士、医师 |
x |
|
|
|
|
x |
|
|
记录病史 |
记录/文档 |
7.1(每次encounter 记录病程记录Document a progress note for each encounter) |
|
医师 |
|
|
|
|
|
x |
|
|
转诊/转科 |
医嘱 |
10.10 (下达转科/转诊医嘱Order provider referral) |
|
医师 |
|
x |
|
|
|
x |
|
|
传输文档 |
传送 |
12.13(接收来自其他机构的病历摘要Receive patient summary record from other providers), 2.2(确认病历摘要的接收Acknowledge receipt of clinical summary), 19.5(传输病历摘要Transmit clinical summary) |
|
护士、医师助理 |
|
|
|
|
|
|
|
医师评估ED treatment (Clinician assessment |
转诊审查 |
review |
2.2临床摘要接收确认(Acknowledge receipt of clinical summary) |
|
护士、医师 |
x |
|
|
x |
|
x |
|
|
下达检验医嘱 |
医嘱 |
10.4(下达检验医嘱Order lab study), 10.2(影像检查diagnostic imaging procedure), 10.8(手术操作procedure), 12.2(接收检验结果Receive clinical lab test result), 17.2(接收LOINC编码的检验结果Review clinical lab tests received with LOINC codes),20.13(依据检验结果 更新病历信息Update patients record based on lab test result |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
诊断 |
记录/文档 |
7.1(记录每个encounter的病程记录) |
|
医师 |
|
|
|
|
|
|
|
|
下达处方 |
review 医嘱 |
10.5-7(下达药嘱Order medication), 13.1(依据CDS规则的推荐疗法 建议调整治疗Recommend care modifications based on clinical decision support rules), 19.6 (传输电子处方/药嘱 Transmit electronic permissible medication order (prescription)) |
|
医师 |
x |
x |
x |
x |
|
x |
|
Patient disposition |
Disposition patients |
执行 |
9.1-2(告知病人随访和预防保健Notify patients for follow-up care and preventive care), 10.10(下达转诊医嘱Order provider referral) |
|
护士、医师助理 |
|
x |
|
|
|
x |
| 门诊手术 |
术前阶段 |
登记 |
记录 |
1.16 (访问患者人口学信息), 7.6 (记录出生日期), 7.9-12 (记录民族、性别、身高、成长曲线), 7.14 (记录医保类型), 7.25 (记录使用语言), 7.28 (记录种族), 7.34(记录吸烟状态), |
|
挂号人员 |
|
|
|
|
|
x |
|
|
测量、记录生命体征 |
记录 |
7.40(记录生命体征 vital signs); 7.41(记录体重weight) |
|
护士、医师助理 |
x |
|
|
x |
|
x |
|
|
病人与手术匹配 |
执行 |
|
|
医师、医师助理、护士 |
|
|
|
|
|
|
|
|
护士术前检查/评估 |
医嘱、执行 |
|
|
护士、医师助理 |
x |
|
|
x |
|
x |
|
|
术前用药 |
医嘱 |
10.5-7(下达药嘱Order medication), 13.1(基于CDS规则推荐的治疗方案调整Recommend care modications based on clinical decision support rules),17.9(回顾所提供的患者教育Review education provided) |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
转移至手术室 |
通知 |
|
|
护士、医师助理 |
|
|
|
|
|
|
|
|
移交 |
通知 |
2.2(确认临床摘要的接收Acknowledge receipt of clinical summary), 19.5(传输摘要信息Transmit clinical summary),12.13(接收其他机构的病人摘要记录receive patient summary allergy record from other providers) |
|
护士、医师助理 |
|
x |
|
|
|
x |
|
手术室阶段 |
准备设备 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
确认病人 |
确认 |
|
|
|
|
|
|
|
|
|
|
|
麻醉操作 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
手术操作 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
创建手术记录 |
创建 |
7.1(为每次encounter记录病程记录Document a progress note for each encounter) |
|
医师 |
x |
|
x |
x |
|
x |
|
|
下达医嘱 |
医嘱 |
10.1-10(下达所有类型的医嘱Order--all types) |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
移交 |
通知 |
12.13(收到来自其他机构的患者病历摘要Receive patient summary record from other providers), 2.2(确认接收Acknowledge receipt of clinical summary), 19.5(传输患者摘要信息Transmit clinical summary) |
|
护士、医师助理 |
|
x |
|
|
|
x |
|
术后阶段 |
转移到康复科室 |
通知 |
|
|
|
|
|
|
|
|
|
|
|
术后检验 |
医嘱 |
10.4(下达检验医嘱Order lab study), 10.8(下达医嘱套餐Order order set),10.9(下达手术医嘱Order procedure) |
|
|
x |
|
|
x |
|
|
|
|
疼痛管理 |
执行 |
|
|
|
x |
x |
x |
x |
|
x |
|
|
出院 |
创建 |
9.1-2(告知病人随访和预防保健Notify patients for follow-up care and preventive care), 10.10(下达转诊医嘱Order provider referral)2.1(确认接受教育Acknowledge education receipt |
|
医师助理、护士、医师 |
|
|
|
|
|
|
| 住院病人住院 |
|
|
|
|
|
|
|
|
|
|
|
|
|
入院 |
测量、记录生命体征 |
记录 |
7.40(记录生命体征 vital signs); 7.41(记录体重weight) |
|
护士、医师助理 |
x |
|
|
x |
|
x |
|
|
病人转移 |
通知 |
|
|
|
|
|
|
|
|
|
|
|
移交 |
通知 |
12.13(收到来自其他机构的患者病历摘要Receive patient summary record from other providers), 2.2(确认接收Acknowledge receipt of clinical summary), 19.5(传输患者摘要信息Transmit clinical summary) |
|
医师助理、护士、医师 |
|
x |
|
|
|
x |
|
检查 治疗 |
病史 体格检查 |
回顾 |
1.1-28 (访问医疗记录中的所有信息Access - all information in medical record) |
|
医师 |
x |
|
|
x |
|
x |
|
|
询问病人 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
记录病史 |
文档/记录 |
7.1(为每次encounter记录病程记录Document a progress note for each encounter) |
|
医师助理、护士、医师 |
|
|
|
x |
|
x |
|
|
下达检验医嘱 |
医嘱 |
10.4(下达检验医嘱Order lab study) |
|
医师 |
|
|
|
|
|
|
|
|
下达影像检查医嘱 |
医嘱 |
10.2(下达诊断学影像检查医嘱Order diagnostic imaging procedure) |
|
医师 |
x |
|
|
x |
|
x |
|
|
回顾先前的检验结果 |
回顾 |
2.3(确认接收来自其他机构的诊断学检查结果Acknowledge receipt of diagnostic test results from other providers), 12.2(接收检验结果Receive clinical lab test result), 17.11-12(回顾人可读的电子格式的检验结果 其中包含了编码数据Review lab results electronically in human readable format, incorporated as codified data) |
|
医师、护士 |
|
|
|
|
|
|
|
|
诊断 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
下达处方 |
回顾、医嘱 |
10.5-7(下达药嘱Order medication), 13.1(依据CDS规则的推荐疗法 建议调整治疗Recommend care modifications based on clinical decision support rules), |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
治疗 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
给药 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
移交 |
通知 |
12.13(收到来自其他机构的患者病历摘要Receive patient summary record from other providers), 2.2(确认接收Acknowledge receipt of clinical summary), 19.5(传输患者摘要信息Transmit clinical summary) |
|
医师助理、护士、医师 |
|
x |
|
|
|
x |
|
转科 |
转到ICU 高护病房 |
通知 |
|
|
|
|
|
|
|
|
|
|
|
移交 |
通知 |
12.13(收到来自其他机构的患者病历摘要Receive patient summary record from other providers), 2.2(确认接收Acknowledge receipt of clinical summary), 19.5(传输患者摘要信息Transmit clinical summary) |
|
医师助理、护士、医师 |
|
x |
|
|
|
x |
|
出院 |
出院指导 |
创建 |
2.1(确认接受教育Acknowledge education receipt), 9.1-2(告知病人随访和预防性护理Notify patients for follow-up care and preventive care) |
|
医师助理、护士 |
|
|
|
|
|
|
|
|
转移病人 |
通知 |
|
|
|
|
|
|
|
|
|
| 住院病人手术 |
术前阶段 |
登记 |
记录 |
1.16 (访问患者人口学信息), 7.6 (记录出生日期), 7.9-12 (记录民族、性别、身高、成长曲线), 7.14 (记录医保类型), 7.25 (记录使用语言), 7.28 (记录种族), 7.34(记录吸烟状态), |
|
挂号人员 |
|
|
|
|
|
x |
|
|
测量、记录生命体征 |
记录 |
7.40(记录生命体征 vital signs); 7.41(记录体重weight) |
|
护士、医师助理 |
x |
|
|
x |
|
x |
|
|
病人与手术匹配 |
执行 |
|
|
医师、医师助理、护士 |
|
|
|
|
|
|
|
|
护士术前检查/评估 |
医嘱、执行 |
|
|
护士、医师助理 |
x |
|
|
x |
|
x |
|
|
术前用药 |
医嘱 |
10.5-7(下达药嘱Order medication), 13.1(基于CDS规则推荐的治疗方案调整Recommend care modications based on clinical decision support rules),17.9(回顾所提供的患者教育Review education provided) |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
转移至手术室 |
通知 |
|
|
护士、医师助理 |
|
|
|
|
|
|
|
|
移交 |
通知 |
2.2(确认临床摘要的接收Acknowledge receipt of clinical summary), 19.5(传输摘要信息Transmit clinical summary),12.13(接收其他机构的病人摘要记录receive patient summary allergy record from other providers) |
|
护士、医师助理 |
|
x |
|
|
|
x |
|
手术室阶段 |
准备设备 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
确认病人 |
确认 |
|
|
|
|
|
|
|
|
|
|
|
麻醉操作 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
手术操作 |
执行 |
|
|
|
|
|
|
|
|
|
|
|
创建手术记录 |
创建 |
7.1(为每次encounter记录病程记录Document a progress note for each encounter) |
|
医师 |
x |
|
x |
x |
|
x |
|
|
下达医嘱 |
医嘱 |
10.1-10(下达所有类型的医嘱Order--all types) |
|
医师 |
x |
x |
x |
x |
|
x |
|
|
移交 |
通知 |
12.13(收到来自其他机构的患者病历摘要Receive patient summary record from other providers), 2.2(确认接收Acknowledge receipt of clinical summary), 19.5(传输患者摘要信息Transmit clinical summary) |
|
护士、医师助理 |
|
x |
|
|
|
x |
|
术后阶段 |
转移到康复科室 |
通知 |
|
|
|
|
|
|
|
|
|
|
|
术后检验 |
医嘱 |
10.4(下达检验医嘱Order lab study), 10.8(下达医嘱套餐Order order set),10.9(下达手术医嘱Order procedure) |
|
|
x |
|
|
x |
|
|
|
|
疼痛管理 |
执行 |
|
|
|
x |
x |
x |
x |
|
x |
|
|
出院 |
创建 |
9.1-2(告知病人随访和预防保健Notify patients for follow-up care and preventive care), 10.10(下达转诊医嘱Order provider referral)2.1(确认接受教育Acknowledge education receipt |
|
医师助理、护士、医师 |
|
|
|
|
|
|
|