D
Clinical Domains for Patient Safety

Consolidated Health Informatics Initiative Clinical Domain Areas

Additional Domains for Patient Safety

Demographics

 

Diagnosis/problem lists for:

Signs

Symptoms

Diseases

Social problems

Patient risk factors/precursors (e.g., designation of comorbid diagnosis)

Interventions/procedures including:

Laboratory orders

Laboratory results contents

Complications associated with specific procedures

Encounters

Episodes

 

Process-specific risk factors (e.g., managing coronary health failure)

 

Departmental risk factors (e.g., delays in the emergency room)

 

Clinical data measures for health conditions

Medications including:

Clinical drugs

Warnings

Alternative medicines

Nutritional supplements

Vitamins



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OCR for page 427
Patient Safety: Achieving a New Standard for Care D Clinical Domains for Patient Safety Consolidated Health Informatics Initiative Clinical Domain Areas Additional Domains for Patient Safety Demographics   Diagnosis/problem lists for: Signs Symptoms Diseases Social problems Patient risk factors/precursors (e.g., designation of comorbid diagnosis) Interventions/procedures including: Laboratory orders Laboratory results contents Complications associated with specific procedures Encounters Episodes   Process-specific risk factors (e.g., managing coronary health failure)   Departmental risk factors (e.g., delays in the emergency room)   Clinical data measures for health conditions Medications including: Clinical drugs Warnings Alternative medicines Nutritional supplements Vitamins

OCR for page 427
Patient Safety: Achieving a New Standard for Care Consolidated Health Informatics Initiative Clinical Domain Areas Additional Domains for Patient Safety Allergic reactions Adverse drug events (ADE) Over-the-counter medications Previous known adverse drug reactions Triggers Medication orders Drug interactions Patient-specific drug dosing Diagnosis-specific drug indications Diagnosis-specific drug contraindications Text-based reports including: Clinical document architecture Clinical document naming Clinical template History and physical including: History Vital signs Anatomy Exam findings Functional status Nutritional status Discharge or treatment plan Determinants for genetic testing/screening of family-related diseases Immunizations     Provider information Training level, cultural factors, speaking language, health Population health including: Nosocomial infections reporting Reportable infections reporting Other reportable conditions Hospital errors other than ADE Emergency room trauma reporting Other national health statistics Near misses Patient complaints Readmission indicators Performance measurement Causal factors Malpractice claims Risk management reports Potential adverse events assessment through electronic surveillance Genes and proteins Pharmacogenomic markers for drug response or drug complication Multimedia including but not limited to: Image Audio Waveforms  

OCR for page 427
Patient Safety: Achieving a New Standard for Care Consolidated Health Informatics Initiative Clinical Domain Areas Additional Domains for Patient Safety Nursing including: Diagnoses Interventions Goals and outcomes Process-specific nursing factors Acuity levels for nurse staffing Physiology     Knowledge bases (systematic reviews of): Clinical guidelines Medical literature Health outcomes data Disease registries   Patient self-management Data set and guidelines for self-care Rx interaction program access Functioning and disability Rehabilitation therapies Respiratory Occupational Speech, etc. Supplies including: Ontology for the ordering physician Medical devices Medical device simulations and testing   Organizational process factors Organizational risk factors Hazard analysis Chemicals (Unified Medical Language System—UMLS)   Billing (Health Insurance Portability and Accountability Act, Administrative Simplification, Transactions and Code Sets) Data from claims attachment Scientific/fundamental (UMLS)   Units (UMLS)