Glossary

Name Description Image
Activities and Interventions​

​A discipline specific list of tasks (requests) generated from orders for a patient. This tool helps staff organise and manage their tasks.

Activity Timeline​

A tool that shows an overview of activities, such as medications due, patient assessments and patient care, for the clinican’s group of patients. Shown in a bar graph format at the base of the Care Compass screen.

Ad Hoc

This is a forms index. If you require a form go to the Adhoc tab in the Navigation Toolbar – the grey ribbon at the top of the screen.

​Admit Discharge Transfer (ADT)​

​This term refers to changes made to a person’s status (admission or discharge) or location (transfer) within the health care facility or associated facilities.

Alert​

​Alerts your attention to certain high risk issues. Entered through the table of contents under Dx, Problems/Alerts. Navigate to the Problem section (bottom half) enter your alert through the folders at the bottom of the page.

Bag by Bag Infusion

A Continuous infusion with a set number of bags – The doctor enters number of bags that they want in the order and once that number of bags has been administered, the Nurse/Midwife can complete the order.

​Banner Bar​

​The blue header section of a patient’s EMR. This includes essential patient information and is displayed on every page of the patient record.

Bolus

Single large volume infusion.

​Care Compass​

A view of a nurse’s allocated patients. A nurse will view, organise and prioritise patient care via Care Compass. This is a summary of patient activities and access to documentation.

Cerner

​Cerner is the supplier of the Electronic Medical Record at Western Health.

The expertise of hundreds of Western Health clinicians have informed the development and design of a Cerner Electronic Medical Record that specifically suits Western Health’s workflows and processes.

C​hapters​

​Sections within a Powerform template that are organised by related topics.

Co- signer​

​Person who signs off on a document to indicate that the contents of the document are accurate or that an order is approved.

​Complete Status

​A status indicating that an order has had all necessary action taken.

Container ID​

​A single letter that uniquely identifies the containers and volume associated with each accession number.

​Continuous Notes

​Displays the patient documentation in chronological order.

​Current State​

​The current processes of our day to day work.

Customisation​

​The ability for staff to customise their view in the EMR.

Customise view

Located in iView, this allows for further customisation of the bands

Document in Plan​

​Functionality allowing nursing and Allied Health staff to review and sign off on IPOC’s.

Downtime

​Any period of time during which the system is unavailable to users.

EDIS​

​EDIS is the name of an emergency department information system. This will continue to be used as per current process, alongside the EMR.

E​lectronic​ Medical Record or EMR

An electronic version of a patient’s hospital medical record.

Electronic Signature​

​This is equivalent to your handwritten signature.

​EMR End User

​All staff who will use the EMR in their provision of clinical care.

​EMR Super User

A Western Health staff member who has attended additional training to develop a higher level of expertise about the functional aspects of their own disciplinary workflows.

Encounter​

​One or more episodes of patient care in a single visit. The episodes of care must be at a single hospital campus.

E​ncounter​ number

​An internal number assigned by the system for each patient encounter. Another term is Financial Number (FIN) or visit number.

F​ace up​

​Information that is visible on the page.

Financial Number (FIN)​

​​This is an internal number assigned by the system for each patient encounter. Another term for encounter number or visit number.

Flowsheet​

​A spreadsheet of a selected patient’s clinical results for a certain time span.

​Future State​

​What the workflow and EMR will be once we Go- Live.

​Go- Live Implementation​

​The time that a specific site will start to use the EMR.

GP View​

Provides referral and GP information.

HTS​

​Health Technology Solutions, part of the Health Technology branch at the Department of Health and Human Services.

InPatient Summary MPage​

​This is an MPage summary of the patient’s current inpatient encounter. This is populated from IView and Power forms.

Interactive View (Iview)​

​The pages in which nursing staff will chart the majority of patient care.

Interdisciplinary Plan of Care (IPOC)​

​IPOC’s are care plans that are customised to meet the patients care needs.  IPOCs consist of outcomes, interventions and tasks.

Intermittent Infusions

Intermittent infusions are those with a frequency (e.g. antibiotics). These will sit in the ‘scheduled’ section of the MAR. These medications will now have the diluent and diluent volume in the name of the medication.

ISBAR Handover MPage​

​ISBAR is the prefered format used by Western Health to handover patients. The ISBAR handover is a patient summary page built into the EMR to be used for handover.

IV Sets

Any infusion containing 2 or more ingredients. This includes a Diluent (fluid) + Additive(medication) = IV Set.

loc​

​An abbreviation of location.

​Mandatory Fields

​These are fields that must be completed to progress. These are indicated by being in bold with a preceding asterisk and the field having a yellow background. Please see to the right for an example.

The icon
is an indicator that there are mandatory fields to be completed.

MAR Summary​

​An overview of the patient’s medications, including last doses given and discontinued medications.

M​edical Record Number (MRN)​

​The unique identifier for each patient. The UR (URN) number is also referred to as the MRN number.

Medication Administration Record (MAR)​

​The electronic drug chart where clinicians will document administration of medications.

Medication Administration Wizard

The Medication Administration Wizard (MAW) supports Positive Patient Identification (PPID) by incorporating scanning the patient wristband, and the displaying medications due in the administration window

​Message Centre

​The default page for medical officers when they login. It displays results for endorsement, documents for co-sign and notifications. It is not a communication tool between clinicians

M​illenium Page (M Page)​

​Collates information from various parts of the EMR to create a view that informs workflows. eg ISBAR Handover MPage.

Modification Icon

This icon appears after there has been a modification to original content.  For example, if you open the powerform and modify the original answer/s, when the powerform is reopened this icon will appear next to the modified area.

​Multi Patient Task List

​A teams list of patients. Where clinical team members can view referral and review orders placed for their discipline.

My Health Record​

​An online summary of a person’s health information which can be accessed at any time by the person and/or their health care providers. This is an Australian Government initiative.

Navigator​

​In PowerChart, the navigator is the left panel of the flowsheet window that lists types of clinical events with associated results for the selected time frame.

Optimisation​

​This is a process to continually enhance the EMR post Go-Live.

​Order Sentences

​’Order sentences’ are selected when typing in the name of an order in

The purpose is to make ordering quicker by filling in a number of “order entry fields” with one click. These “order entry fields” can be altered post selection so it is not necessary to find exactly the right “order sentence.”

​Order Set

​A group of related requests to address a common clinical scenario. In other health services this may be referred to as a “Powerplan” or “Care Set.”

Orders

​An electronic communication of a request such as medications, referrals, pathology, care tasks etc..

​Orders for Signature (Scratch pad)​

​This displays after adding an order and allows you to order multiple requests prior to signing.

Pathology Collection List

A printable list of specimens to be collected for laboratory testing. Collection lists include patient demographic information, order information, collection requirements, and specimen labels.

Pathology Collection Status​

​The state or condition of the specimen in the collection process. Pending status indicates that the order is scheduled for a future collection list; Dispatch indicates the specimen labels have been generated; Missed indicates an unsuccessful collection; and Collected means a specimen has been obtained.

​Patient Demographics/ Information

​Non clinical information defined for the individual person or encounter. This information is pulled from iPM.

Patient Provider Relationship (PPR) Summary​

A list of everyone who has established a relationship with the patient.

Planned Orders​

​Order sets that exist waiting for staff to decide to activate them, eg pre-admission clinic.

Positive Patient Identification (PPID)​

​Positive patient identification (PPID) is used to confirm patient identification electronically in the EMR to prevent of errors relating to medication administration and specimen collection

P​owerchart​

​The electronic version of the patient’s medical record.

Powerforms​

​A series of templates for clinical documentation. They are designed to provide forms to document patient information.

Problems​

​List of everything that is an active condition for the patient. This includes the diagnosis being addressed, comorbidities and clinical alerts.

Proxy​

​A person designated to perform a task or review results for another clinician.

Relationship

​The role defined between a health care professional and a patient. In PowerChart, a user establishes a relationship with a patient prior to opening the patient’s chart

Specimen Collection

The Specimen Collection Tool enables the clinician to view specimens that need to be collected

​Specimen Label

An EMR label that is affixed to a specimen container for identification purposes. Each label is specific to the test requested and provides additional information for the clinician.

Split Window icon

The split window allows you to view the two sections of iView at the same time

Standard Nomenclature of Medicine (SNOMED CT)

​Collection of medical terms and codes used in clinical documentation and reporting.

Subject Matter Expert (SME)

​Western Health clinical care and support staff who have been participating in the EMR development, and engaging with stakeholders to inform the EMR design to meet Western Health workflows.​

Summary MPage

This is an MPage summary of the patient’s current inpatient encounter. This is populated from IView and Power forms.

Table Of Contents (TOC)

The grey list called ‘Menu’ down the left hand side of the patient chart. It lists the main pages of the medical record.

​Task Manager

​Medical officer task management tool. This is used in addition to the current communication process of paging or calling the doctor.

Tear Off

When you view the patient chart, you can tear off (display a copy of) the page you are viewing and move it aside on your desktop. You can continue to navigate to other parts of the chart while keeping important data in view. This aids in making comparisons or sometimes in completing data entry boxes in forms or documentation or writing orders.

 

Toolbar (Ribbon bar)

The grey bands at the top of the screen that allow you to navigate within the EMR.

Truly Continuous Infusion

An infusion without any duration/stop time which remains active on the MAR until discontinued by the doctor. A Nurse/Midwife can continue to hang new bags/titrate rate (as per policy) without the doctor having to modify the order.

Visit List

​A complete list of patient encounters plus encounter specific administrative data.

​Visit Number

​An internal number assigned by the system for each patient encounter. Another term is Financial Number (FIN) or visit number.

Volume

​“Volume” in this context refers to amount or quantity. No other term would cover all the concepts required.

Workflows

​The steps you take as you do your job and the order in which you do them.

WoW

​Workstation on Wheels. Computer on Wheels.