Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record.

A system of record keeping in which a list of the patient's problems is made and all history, physical findings, laboratory data, etc. pertinent to each problem are placed under that heading.

Information systems, usually computer-assisted, designed to store, manipulate, and retrieve information for planning, organizing, directing, and controlling administrative activities associated with the provision and utilization of ambulatory care services and facilities.

Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online consumer health information that is relevant to the health conditions and treatments related to a specific patient.

Recording of pertinent information concerning patient's illness or illnesses.

Systems composed of a computer or computers, peripheral equipment, such as disks, printers, and terminals, and telecommunications capabilities.

Protective measures against unauthorized access to or interference with computer operating systems, telecommunications, or data structures, especially the modification, deletion, destruction, or release of data in computers. It includes methods of forestalling interference by computer viruses or so-called computer hackers aiming to compromise stored data.

Integrated, computer-assisted systems designed to store, manipulate, and retrieve information concerned with the administrative and clinical aspects of providing medical services within the hospital.

The attitude and behavior associated with an individual using the computer.

The procedures involved in combining separately developed modules, components, or subsystems so that they work together as a complete system. (From McGraw-Hill Dictionary of Scientific and Technical Terms, 4th ed)

A system containing any combination of computers, computer terminals, printers, audio or visual display devices, or telephones interconnected by telecommunications equipment or cables: used to transmit or receive information. (Random House Unabridged Dictionary, 2d ed)

The visual display of data in a man-machine system. An example is when data is called from the computer and transmitted to a CATHODE RAY TUBE DISPLAY or LIQUID CRYSTAL display.

Integrated set of files, procedures, and equipment for the storage, manipulation, and retrieval of information.

Small computers using LSI (large-scale integration) microprocessor chips as the CPU (central processing unit) and semiconductor memories for compact, inexpensive storage of program instructions and data. They are smaller and less expensive than minicomputers and are usually built into a dedicated system where they are optimized for a particular application. "Microprocessor" may refer to just the CPU or the entire microcomputer.

The privacy of information and its protection against unauthorized disclosure.

The portion of an interactive computer program that issues messages to and receives commands from a user.

Computer-based information systems used to integrate clinical and patient information and provide support for decision-making in patient care.

The services rendered by members of the health profession and non-professionals under their supervision.

A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records.

A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of medical care.

Organized activities related to the storage, location, search, and retrieval of information.

The creation and maintenance of medical and vital records in multiple institutions in a manner that will facilitate the combined use of the records of identified individuals.

Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress.

Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.

Care which provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (JAMA 1995;273(3):192)

Attitudes of personnel toward their patients, other professionals, toward the medical care system, etc.

Longitudinal patient-maintained records of individual health history and tools that allow individual control of access.

Sequential operating programs and data which instruct the functioning of a digital computer.

The application of computer and information sciences to improve dental practice, research, education and management.

Organized procedures for establishing patient identity, including use of bracelets, etc.

Compilations of data on hospital activities and programs; excludes patient medical records.

Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.

Management of the acquisition, organization, storage, retrieval, and dissemination of information. (From Thesaurus of ERIC Descriptors, 1994)

Data collected during dental examination for the purpose of study, diagnosis, or treatment planning.

Predetermined sets of questions used to collect data - clinical data, social status, occupational group, etc. The term is often applied to a self-completed survey instrument.

The broad dissemination of new ideas, procedures, techniques, materials, and devices and the degree to which these are accepted and used.

A legal concept for individuals who are designated to act on behalf of persons who are considered incapable of acting in their own behalf, e.g., minors and persons found to be not mentally competent.

The room or rooms in which the physician and staff provide patient care. The offices include all rooms in the physician's office suite.

The study and practice of medicine by direct examination of the patient.

A specified list of terms with a fixed and unalterable meaning, and from which a selection is made when CATALOGING; ABSTRACTING AND INDEXING; or searching BOOKS; JOURNALS AS TOPIC; and other documents. The control is intended to avoid the scattering of related subjects under different headings (SUBJECT HEADINGS). The list may be altered or extended only by the publisher or issuing agency. (From Harrod's Librarians' Glossary, 7th ed, p163)

Process of teaching a person to interact and communicate with a computer.

Generating, planning, organizing, and administering medical and nursing care and services for patients.

The capacity of an organization, institution, or business to produce desired results with a minimum expenditure of energy, time, money, personnel, materiel, etc.

The sum total of nursing activities which includes assessment (identifying needs), intervention (ministering to needs), and evaluation (validating the effectiveness of the help given).

The field of information science concerned with the analysis and dissemination of medical data through the application of computers to various aspects of health care and medicine.

The commitment in writing, as authentic evidence, of something having legal importance. The concept includes certificates of birth, death, etc., as well as hospital, medical, and other institutional records.

Specifications and instructions applied to the software.

Hospital department responsible for the creating, care, storage and retrieval of medical records. It also provides statistical information for the medical and administrative staff.

Systems used to prompt or aid the memory. The systems can be computerized reminders, color coding, telephone calls, or devices such as letters and postcards.

Hospitals providing medical care to veterans of wars.

Individuals licensed to practice medicine.

The freedom of patients to review their own medical, genetic, or other health-related records.

Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers.

Medical complexes consisting of medical school, hospitals, clinics, libraries, administrative facilities, etc.

Information systems, usually computer-assisted, that enable providers to initiate medical procedures, prescribe medications, etc. These systems support medical decision-making and error-reduction during patient care.

Organized systems for providing comprehensive prepaid health care that have five basic attributes: (1) provide care in a defined geographic area; (2) provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; (3) provide care to a voluntarily enrolled group of persons; (4) require their enrollees to use the services of designated providers; and (5) receive reimbursement through a predetermined, fixed, periodic prepayment made by the enrollee without regard to the degree of services provided. (From Facts on File Dictionary of Health Care Management, 1988)

Introduction of changes which are new to the organization and are created by management.

Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information.

A cabinet department in the Executive Branch of the United States Government concerned with overall planning, promoting, and administering programs pertaining to VETERANS. It was established March 15, 1989 as a Cabinet-level position.

Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data.

A type of MICROCOMPUTER, sometimes called a personal digital assistant, that is very small and portable and fitting in a hand. They are convenient to use in clinical and other field situations for quick data management. They usually require docking with MICROCOMPUTERS for updates.

The levels of excellence which characterize the health service or health care provided based on accepted standards of quality.

The terms, expressions, designations, or symbols used in a particular science, discipline, or specialized subject area.

Customer satisfaction or dissatisfaction with a benefit or service received.

A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence.

Descriptions and evaluations of specific health care organizations.

Laboratory and other services provided to patients at the bedside. These include diagnostic and laboratory testing using automated information entry.

Organized collections of computer records, standardized in format and content, that are stored in any of a variety of computer-readable modes. They are the basic sets of data from which computer-readable files are created. (from ALA Glossary of Library and Information Science, 1983)

A loose confederation of computer communication networks around the world. The networks that make up the Internet are connected through several backbone networks. The Internet grew out of the US Government ARPAnet project and was designed to facilitate information exchange.

Patterns of practice related to diagnosis and treatment as especially influenced by cost of the service requested and provided.

Organized services in a hospital which provide medical care on an outpatient basis.

Extensive collections, reputedly complete, of facts and data garnered from material of a specialized subject area and made available for analysis and application. The collection can be automated by various contemporary methods for retrieval. The concept should be differentiated from DATABASES, BIBLIOGRAPHIC which is restricted to collections of bibliographic references.

Health care services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. The services may be a part of a hospital, augmenting its inpatient services, or may be provided at a free-standing facility.

The concept concerned with all aspects of providing and distributing health services to a patient population.

Health services, public or private, in rural areas. The services include the promotion of health and the delivery of health care.

A medical specialty concerned with the provision of continuing, comprehensive primary health care for the entire family.

An aspect of personal behavior or lifestyle, environmental exposure, or inborn or inherited characteristic, which, on the basis of epidemiologic evidence, is known to be associated with a health-related condition considered important to prevent.