Patient Care - Reference Manual - Physician - Fraser Health Authority

EditEMREMR NumberFunctionFuture OrderHot KeyIdentifying aPatientInpatientsChange/add to existing information.Enterprise Medical Record – A MEDITECH module that collects,stores, and displays clinical data for patients within Fraser Health.Allows you to view patient clinical data and departmental results andreports. Patient information processed by EMR ranges fromdemographic and status data to orders performed. Because thisinformation is never purged from EMR, patient histories arepermanently maintained.A unique number assigned to an individual receiving services by theEMR Module. This number identifies an individual's medical recordsthroughout the individual's lifetime. Clinicians can identify individualsby EMR number at most patient prompts. The number accompaniesother demographic information (such as account number andadmitting provider) on many screens throughout EMR.A routine that is available from within a process routine. For examplein the Order Entry module, Cancel Orders is a function in the ReviewOrders routine.Orders to be done after the current date.A keystroke that invokes a function, routine or menu. A hot keyIs provided as an alternative to using a mouse. For example, inprocess routines, a letter appears on each process button. To accessa button, type the letter, which is the hot key. On the tab titles,the first letter is underlined and can be used as a hot keyThere are 4 ways to identify a patient:• Full Name: Start with the last name. Separate first name fromlast name with a comma. No spaces between first and lastname. SMITH,JOHN• Partial Name: Start with the last name. Separate first namefrom last name with a comma. No spaces between first andlast name. SMI,J• Account Number: The two letters are the site mnemonic andthen a series of number• Recall: If working in a routine or signed off the computer andreturned and would like to enter information on the samepatient, press the spacebar and then the enter key. the keyPatients staying in hospital for more than 6 hours and/or admitted bya physician.Health InformaticsHealth Information Systems and Services© Fraser Health Authority, 2006. All rights reserved.66