Patient Chart Order System

Traditionally different paper patient chart order systems have been used for documentation of all activities planned and performed. For each patient this could be hundreds and sometimes thousands of papers sorted by care occasion for each level of care. Also the documentation is sometimes incomplete and historical events and circumstances are hard to find. Recently some aspects of patient care such as laboratory lists and other tests and results have been included in electronic systems. Since medication chart orders belong to the most complicated issues this is often the last to be integrated. 

Detecting the incidence and type of adverse drug events (ADEs) and medication errors is important for improving the quality of health care delivery. Problems include missing dose, wrong dose, frequency, and route errors. The consequence (ADE) of the errors depends on medication and patient factors as described previously. Some of these problems are organisational and related to chart order system and prescribing. 

Decision-support systems, wherein transactions are screened according to a set of rules, add an additional layer of value to transactional systems. To be effective, such systems require that rules be invoked in real time and draw on data relevant to the transaction. For example, a drug order may be contraindicated based on allergies, or a laboratory order may be contraindicated by the results of previous tests or applicability in the context of the patient s condition as recorded in the electronic chart. The implementation of decision-support tectoology requires significant effort in the development of acceptable rules and the processing power to process them in real time. 

These electronic devices provide instant access to patient information. Caregivers can electronically assess, monitor, and chart patient care electronically. Some hospitals use coordinated systems that address patient care, medication verification, and computerized provider order entry. 

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