ient Clinical Systems- Fundamentals
Name of first screen that user sees when they log in - ANS-Startup activity
List of patients that I am following - ANS-My List
A list of patients that is automatically updated by the system - ANS-System List
Tabs along the left of the screen in a patient's chart - ANS-Activities
How can you tell there is an abnormal value? - ANS-appears in red
Schedule - ANS-list of scheduled surgical cases as well as outpatient appts- 1st startup
activity that surgeons see
Patient List - ANS-all admitted patients you are assigned to
Patient header - ANS-bar across the top of the patient workspace- key pieces of info are
here (mrn, allergies, etc.)
System list shortcut - ANS-
Accordion Report - ANS-allow you to drill down and trend patient info- only info from the
current admission, useful for patients in the ICU or PACU, customizable
Intake/Output activity - ANS-view-only activity used to review a patient's daily intake and
out put in table or graph format
Time Mark - ANS-indicate that they've already seen the notes documented up to this
point
File Time - ANS-time the user clicked Sign and saved the note to the patient's chart
Note Time - ANS-time note was composed
modify an order - ANS-actually means the original order is canceled or discontinued and
a new order is placed
, discontinue an order - ANS-orders that are no longer needed or are being replaced
pended order - ANS-saved order that has not been signed
preference list - ANS-most commonly placed orders for a given unit or specialty
synonym - ANS-different name for same order- use things like brand names,
mnemonics
EnRol - ANS-Enhanced Record Lookup- search against the first few letters
Order requiring cosign - ANS-orders that the physician has to review and give a final
stamp of approval.
principal problem - ANS-main reason for the patient's admisssion
chronic problem - ANS-ongoing problems that will not be resolved before discharge
NoteWriter - ANS-document patient's progess & current condition using point and click
functionality
Macro - ANS-predefined set of values that can be pulled into a note with a click of a
button
Why is it important to update the Problem List? - ANS-current hospitalization,
multi-disciplinary care, future care, decision support, billing, notes, my chart, meaningful
use
Incomplete vs Signed - ANS-
How can physicians ensure they're accurately billing the patient? - ANS--sign notes, be
sure correct problem is identified, review charges
acknowledge orders - ANS-you have seen the order
work list view and filter - ANS-tool to help nurses view and prioritize the task they need
to complete during their shift
How does adding yourself to the treatment team help maintain the system list? - ANS-
Name of first screen that user sees when they log in - ANS-Startup activity
List of patients that I am following - ANS-My List
A list of patients that is automatically updated by the system - ANS-System List
Tabs along the left of the screen in a patient's chart - ANS-Activities
How can you tell there is an abnormal value? - ANS-appears in red
Schedule - ANS-list of scheduled surgical cases as well as outpatient appts- 1st startup
activity that surgeons see
Patient List - ANS-all admitted patients you are assigned to
Patient header - ANS-bar across the top of the patient workspace- key pieces of info are
here (mrn, allergies, etc.)
System list shortcut - ANS-
Accordion Report - ANS-allow you to drill down and trend patient info- only info from the
current admission, useful for patients in the ICU or PACU, customizable
Intake/Output activity - ANS-view-only activity used to review a patient's daily intake and
out put in table or graph format
Time Mark - ANS-indicate that they've already seen the notes documented up to this
point
File Time - ANS-time the user clicked Sign and saved the note to the patient's chart
Note Time - ANS-time note was composed
modify an order - ANS-actually means the original order is canceled or discontinued and
a new order is placed
, discontinue an order - ANS-orders that are no longer needed or are being replaced
pended order - ANS-saved order that has not been signed
preference list - ANS-most commonly placed orders for a given unit or specialty
synonym - ANS-different name for same order- use things like brand names,
mnemonics
EnRol - ANS-Enhanced Record Lookup- search against the first few letters
Order requiring cosign - ANS-orders that the physician has to review and give a final
stamp of approval.
principal problem - ANS-main reason for the patient's admisssion
chronic problem - ANS-ongoing problems that will not be resolved before discharge
NoteWriter - ANS-document patient's progess & current condition using point and click
functionality
Macro - ANS-predefined set of values that can be pulled into a note with a click of a
button
Why is it important to update the Problem List? - ANS-current hospitalization,
multi-disciplinary care, future care, decision support, billing, notes, my chart, meaningful
use
Incomplete vs Signed - ANS-
How can physicians ensure they're accurately billing the patient? - ANS--sign notes, be
sure correct problem is identified, review charges
acknowledge orders - ANS-you have seen the order
work list view and filter - ANS-tool to help nurses view and prioritize the task they need
to complete during their shift
How does adding yourself to the treatment team help maintain the system list? - ANS-
