(Informatics)
Prerequisites
You have access to the following private patient data elements via the Shoreline EHR database.
Patient demographics
Vital signs
Medications
Diagnoses
Labs
Active problems
Visit dates and times
Procedures
Test results
Clinical notes
Questions
Patient demographics
1. Describe which, if any, specific demographic data should be collected and why. This
information is found on the Registration Tab.
Many things are missing in the patient's registration form due to being de-
identified. Such as the patient’s name and contact information. Also, social
security number for billing, address, city, state, and phone number in case
the hospital needs to contact her, and there is no employer information to
know if she is in fact employed, to ensure that her symptoms aren’t work-
related.
EHR Go Knowledge Activity: Applied Data Analytics II (Informatics) IK1024.4 1
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, Vital signs
2. Describe which, if any, specific vitals data should be collected and why. This information
is found on the Vitals Tab.
Vitals that should be collected upon initial contact, or in triage, should be the
patient’s blood pressure, temperature, pulse, and respiration levels. These
should be taken to give the doctor time to assess the overall health of their
patient.
Medications
3. Describe which medication administration fields, if any, should be collected. This
information is found on the Meds Tab and can be examined by clicking on any
administered medication order.
All fields in this section should be entered correctly, including any
medications that the patient is allergic to so that it can be avoided for
treatment. It is also important to document any effects these medications, if
any, have caused after administration and note how well the patient tolerates
it. However, all of this information will be needed for the next shift to review
before they make their rounds to ensure correct medications and dosages are
given.
Diagnoses & Problem lists
4. Describe which diagnosis or problem fields, if any, should be collected and why.
Problems and diagnoses are listed together on the Problems Tab.
This information is important to collect to inform the doctor that the patient
has had complications with her previous pregnancies, which I would consider
EHR Go Knowledge Activity: Applied Data Analytics II (Informatics) IK1024.4 2
Archetype Innovations LLC ©2024