Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Settings The Places Where Care is Delivered
Lecture:Departments and services
Interrelationships between health care organizations
Medical data use and impact
Slide content:Patient Clinical Data Types Narrative, textual Numerical measurements Recorded signals Drawings Photographs and images Shortliffe & Barnett, 2006 17
Slide notes:Several types of data are used to gather and record information. Much of the observational datasuch as patient history, results of physical examination, and procedure and surgery reportsare recorded as narrative data. Numerical measures include weight, vital signs, and volumes. Recorded signals are increasingly digital and can be transferred directly to EHRs. These signals include electrical activity (electrocardiograms) and pressures generated from a variety of monitoring devices, such as blood pressure and other measures of cardiac pressures. Many devices, such as intravenous fluid administration devices and ventilators [ vent - ul -ay- terz ] now have the ability to directly input data into EHRs. Drawings, produced either by hand or with software, provide a record of an observation made to aid in documenting or following the progress of a wound, surgery, injury, and so on. Photographs and images are becoming more common in digital format and allow clinicians to record abnormal findings or wound at admission to better follow the progress. Many health care organizations now record all x-rays and imaging in digital format. 17