Computers in Patient Care, EHR, and Medication Safety

Vocabulary flashcards covering key terms, systems, and concepts related to Electronic Health Records, Barcode Medication Administration, Computerized Provider Order Entry, eMAR, patient safety, and computer hardware/software fundamentals.

Electronic Health Record (EHR)

A digital version of a patient's paper chart containing comprehensive health information collected and maintained by healthcare providers over time.

Patient Identification Information

EHR data category containing the patient's name, age, sex, date of birth, and hospital or medical record number.

Medical History

Section of an EHR containing records of previous illnesses, previous surgeries, previous hospitalizations, and family history.

Current Health Information

EHR category that includes current diagnosis, signs and symptoms, vital signs, and physical assessment findings.

Nursing Documentation

The digital tracking, documentation, and management of patient care by nurses using computer software, including assessments, interventions, care plans, and progress notes.

Accurate Documentation

Recording a patient's health information and nursing care correctly, completely, clearly, and on time.

Paper Records

Physical handwritten or printed medical documents that can be used without computers, but take more time to find, organize, and share.

Barcode Medication Administration (BCMA)

A point-of-care application introduced in 1995 by Sue Kinnick at Colmery-O'Neil Veterans Medical Center that validates medication administration in real-time to enhance patient safety.

5 Rights of Medication Administration

Core verification checks electronically validated by BCMA: Right Patient, Right Medication/Drug, Right Dose, Right Route, and Right Time.

10 Rights of Medication Administration

Comprehensive nursing verification checks: Right Patient, Right Medication (Drug), Right Dose, Right Route, Right Time, Right Documentation, Right Patient Education, Right to Refuse, Right Assessment, and Right Evaluation.

Medication Error

A preventable mistake involving medication that can occur during prescribing, ordering, dispensing, preparing, administering, or monitoring.

Computerized Provider Order Entry (CPOE)

A system where medication orders are entered electronically rather than relying on handwritten orders, helping standardize medication information and integrate with clinical decision-support systems.

High-Alert Medications

Medications bearing a heightened risk of causing significant patient harm if used in error, such as anticoagulants, chemotherapy, electrolyte concentrates, insulin, opioids, and neuromuscular blocking agents.

Electronic Medication Administration Record (eMAR)

A digital chart used by nurses and care workers to track and log patient medications, featuring real-time schedules, exact doses, drug names, times to give drugs, and administration notes.

Drug Interaction

An event occurring when a substance changes how a medicine works, which can cause the drug to stop working, become too strong, or trigger adverse side effects.

Drug-Drug Interaction

A type of interaction where one medicine reacts with another prescription or over-the-counter drug.

Drug-Food/Drink Interaction

An interaction occurring when consumed foods or alcohol alter how the body processes a medication.

Drug-Condition Interaction

A situation where an existing health problem or medical condition makes using a specific medication risky.

Allergy Alert

A notification, label, or medical identification device that warns about harmful allergens or a patient's specific allergy risks to prevent dangerous immune reactions.

Patient Safety

The absence of preventable harm to a patient during healthcare, and the coordinated efforts to protect patients from unnecessary risks caused by healthcare processes.

Healthcare Technology

Tools, machines, software, and systems used to support healthcare services, such as EHRs, imaging devices, monitoring devices, infusion pumps, ventilators, and telemedicine.

Computer

An electronic device that accepts data, processes it according to instructions, stores information, and produces meaningful output.

Hardware

The physical parts of a computer system, consisting of input devices, output devices, storage devices, and processing devices.

Software

Program instructions that direct a computer to perform tasks, categorized into system software and application software.

System Software

Programs that control and manage computer hardware operations, such as Windows and macOS operating systems.

Application Software

End-user programs designed to perform specific tasks, including word processors, web browsers, Hospital Information Systems (HIS), and Electronic Medical Records (EMR).

Central Processing Unit (CPU)

The primary processing device in a computer responsible for handling data, performing calculations, and running programs.

Data

Raw facts entered into a computer system.

Information

Processed data that has been converted into a meaningful output.

Database

An organized collection of structured information stored in a computer system.

Network

A group of computers connected together to share data and resources.

Internet

A global network of interconnected computers.