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ADT (Admissions and Discharge Tracking)
The transactions and tracking of admissions, discharges and transfers both internal and external to the site.
ARRA (American Recovery and Reinvestment Act)
The American Recovery and Reinvestment Act passed in February 2009. The act directs the Health and Human Services Department and several
related federal agencies to develop and implement the processes to support adoption and funding of HIT (Health Information Technology) in
several specific medical settings including Skilled Nursing Facilities (SNF).
Clinical Assessments or Observations
An Electronic Medical Record (EMR) is divided into a number of small input screens. Each screen collects data for a specific set of
tests or observed behaviors, known as a Clinical Assessemnt or Clinical Observation.
CNA (Certified Nursing Assistant)
Much of the primary care in SNFs is delivered by Certified Nursing Assistants. The activities and records of the CNAs is vital to monitoring
and documenting the resident activities on a daily basis.
EHR (Electronic Health Record)
The electronic health record is generally considered to be similar to the EMR except that it includes communication with disparate
clinical systems that allows for the sharing of medical information electronically. To achieve interoperability disparate EMR and
clinical systems must have common methods of communicating electronically that are safe, secure and with communication and data
standards that allow for the sharing to be seamless and accurate.
EMR (Electronic Medical Record)
The electronic medical record is generally considered to be the composite medical of all information collected and maintained
in a single medical setting such as a SNF. A complete EMR will allow for medical information collection, access on demand and
retention for all medical and patient information that is appropriate and required to accomplish the desired patient care and
regulatory compliance. The quality of an EMR should be measured and evaluated based on several factors including: ease of use,
adaptability to good practices and workflow in the care setting, functional efficiency and the quality of information captured
and available for use within the care setting.
Interoperability
Interoperability describes the electronic sharing of information or actual care related communications between disparate EMRs
and EHRs. The communication of information may be directly through EDI or through regional or national data repositories that
are designed and managed for this purpose. The regional and nation organization are usually referred to as HIE (health information
exchange) or RHIO (regional health information organization). For LTC the most common examples of interoperability are direct
communication with vendor pharmacies, labs and hospitals.
(LTC) Long-Term Care
LTC generally refers to and includes all settings of post acute care but in some instances only refers to licensed SNFs
(skilled nursing facilities or nursing facilities), ALF (assisted living facilities) and ILF (independent living facilities).
The more global definition for post acute care (PAC) includes other licensed organizations such as: LTC acute hospitals, sub
acute facilities, long term rehab facilities and home health agencies.
(MAR) Medication Administration Record
he medication administration record whether on paper or electronic as an eMAR refers to the functions of medication administration
including clinical documentation. This function done correctly assists and supports the administration of the ordered medications
to the correct patient, at the proper time and with all desired safeguards for patient safety properly followed.
The eMAR has become the desired standard of practice with much its improved quality of information made available in real time. The paper MAR has many weaknesses and possible points of failure when compared with a properly designed and implemented eMAR. The eMAR allows for improved patient safety and enhanced patient care.
POC (Point of Care)
Point of Care documentation refers to the ability to document and record patient care activities and patient observations in a
timely fashion and at the point of care. Properly designed POC devices, tools and systems are fundamental to supporting the workflow
of clinicians to enhance patient care and create operational efficiencies through the use of POC charting. The POC tools and
devices may be implemented in many forms including: computer carts, wall mounted computers, mobile PDAs, and mobile tablet computers.
Near to the point of care devices would include hallway mounted computers or kiosks.
SaaS (Software as as Service)
Software as a Service is generally defined as making the functions of a software system available to a customer through the
internet and with remote hosting of the system. Additionally, not having the application software and mass database storage devices
being maintained or owned by the customer is considered part of the services to be offered. The benefits to the customer of SaaS
are many but most importantly the benefits include a lower cost of acquiring the software’s features and functions, a lower cost to
manage and maintain the system and database environment and reduced complexity and staffing in the customer’s IT and IS organization.
Structured Progress Notes
Progress notes using preformatted clinical phrases, along with clinical pathways and drill down to the
desired level of clinical detail allows for complete clinical documentation and efficiency of entry. This method of clinical
documentation also allows for standardized nomenclature and which supports interoperability directly when the sharing of information
is based on standard data formats and nomenclature. Free form text input of clinical information represents the opposite method to
structured notes.
TAR (Treatment Administration Record)
Similar to the MAR except used for treatments and other patient care activities. The treatment administration record whether
on paper or electronic as an eTAR refers to the functions of treatment administration including clinical documentation. This
function done correctly assists and supports the administration of the ordered treatments to the correct patient, at the proper
time and with all desired safeguards for patient safety properly followed. Wound care and other special treatments can be fully
and correctly documented.
The eTAR has become the desired standard of practice with much its improved quality of information made available in real time. The paper TAR has many weaknesses and possible points of failure when compared with a properly designed and implemented eTAR. The eTAR allows for improved patient safety and enhanced patient care.