The module shall include information on patient registration, visit details, treatment details, referral source, patient follow up;
(admitted, discharged or referred to outpatient clinics ).
The Accident and Emergency (A&E) module should allow the Hospital to record data accurately and quickly for patient treatment. The A&E module should allow users to record casualty details , and `discharge status’. It should also register patients and integrate to the Inpatients module for admitting patients. The module should produce casualty statistics i.e. types of injury, clinic usage, discharge status.
The following has been extracted from a recent RFP. I've included it here for your reference. It may prove useful for anyone preparing such a document.
Please feel free to comment on this list, and propose any items that you think should have been included in this list.
| Accident and Emergency |
| | Description | Accident and Emergency The module shall include information on patient registration, visit details, treatment details, referral source, patient follow up; (admitted, discharged or referred to outpatient clinics ). The Accident and Emergency (A&E) module should allow the Hospital to record data accurately and quickly for patient treatment. The A&E module should allow users to record casualty details , and `discharge status’. It should also register patients and integrate to the Inpatients module for admitting patients. The module should produce casualty statistics i.e. types of injury, clinic usage, discharge status. |
| 1 | | Support concurrent electronic charting of nursing assessments, physician charting and other clinical documentation of patient visit | | 2 | | Support online charting of assessments , of admission notes | | 3 | | Support online charting of allergies | | 4 | | Support physician entry of discharge disposition | | 5 | | Support physician entry of prescriptions | | 6 | | Automatically record and track date , time and ID of clinicians with each electronic chart note or entry | | 7 | | Support bi-directional interface to hospital information system admissions ( ADT ) module to communicate registration transactions and demographic data between systems. | | 8 | | Support bi-directional interface to hospital medical system to retrieve medical record number for Emergency Department patient registrations | | 9 | | Support charge interface to hospital billing system to transmit Emergency Department patient charges | | 10 | | Support bi-directional interface to hospital order and result communication ( reporting ) system to send orders to and receive results from ancillary department information systems . | | 11 | | Support interface to hospital pharmacy system to transmit prescriptions generated in Emergency Department for discharged patients | | 12 | | Support order entry for lab tests | | 13 | | Provide ability to order ‘panels’ of lab tests | | 14 | | Support order entry for diagnostic imaging services including detail for exam , view , urgency , ordering physician and relevant patient history | | 15 | | Support order entry for EKG | | 16 | | Provide ability to limit ordering privileges by user and / or user class | | 17 | | Support entry of reason for test | | 18 | | Support entry of free text ( ex: comments ) with an order | | 19 | | Automatically display allergy information when ordering medications | | 20 | | Support ordering procedures for hospital teaching environments (ex: attending order verification for medical students ) | | 21 | | Automatically flag or alert clinician of abnormal or critical lab values on result screens | | 22 | | Support entry of multiple orders without the need to re-select patient from list, re-enter patient ID , etc.. | | 23 | | Provide ability to assign same nurse to multiple patients in a single step | | 24 | | Provide ability to assign multiple physicians to a patient | | 25 | | Ability to hold a room for a patient before arrival ( ex: ambulance, doctor’s office ) | | 26 | | Support definition of ‘hall beds’ in the system and ability to assign a patient to a hall bed | | 27 | | Allow more than one user to access the same patient record at the same time ( ex: no record lock out ) | | >>> Status Tracking ( by Laps of Time ) | | | | 28 | | Allow to define triage codes with the corresponding descriptions | | 29 | | Capture code and time of triage | | 30 | | Capture time patient is in treatment room | | 31 | | Track all patients in all phases of care | | 32 | | Capture time patient is seen by RN | | 33 | | Capture time medications are administered to patient | | 34 | | Capture time admitting department is called for bed assignment | | 35 | | Provide ability to configure user-defined , emergency department specific patient care events to capture time for tracking purposes | | 36 | | Automatically alert clinicians (ex: visually on tracking screen ) when patient test results are back and available for review | | 37 | | Provide ability to view status of all patients with x-ray orders | | 38 | | Provide ability to view status of all patient with bed request | | 39 | | Provide support and functions for handling a disaster with massive casualties | | 40 | | Maintain database of all patient demographic information and prior ED visit records to access and carry forward into new registrations | | 41 | | Support online retrieval and display of historical emergency department charts for prior patient visits to ED | | 42 | | Automatically generate a unique ED encounter number for each ED patient registration | | 43 | | Support entry of patient’s chief complaint from a pick list ( ex: drop-down box) or using free text entry | | 44 | | Provide ability to enter accident information | | 45 | | Provide ability to enter an expected length of stay | | 46 | | Include specific latex allergy field in registration screen and store in patient’s permanent history for retrieval in future registrations | | 47 | | Provide ‘quick registration’ function to register ‘patient x ’ patient when identity is unknown | | 48 | | Provide ability to merge ‘patient x ‘ charts with final patient chart later | | 49 | | Support pre-registration of a patient if patient is en-route ( ex: ambulance , doctor’s office ) | | 50 | | Provide ability to bypass triage function in registration process, if necessary | | 51 | | Support the production of bar-coded patient labels | | 53 | | Account for police notification and Medico Legal Cases | | 54 | | Allow to print the patient attendance register | | 55 | | Produce end of shift reports | | 56 | | Produce statistical reports on casualties , attendance , admission from A&E | | 59 | | Admissions, Transfers & Discharges | | 60 | | Order Results Management | | 61 | | Financials and Billing | |