The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties
The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. Which of the following are CPR components? Select all that apply. 1. Lack of confidentiality
2. Direct entry for physicians will be available
3. Tools cannot measure cost
4. Provides sporadic access to data
5. Provides a patient problem list
5
Rationale: The following are the IOM's CPR components:
-Provides a problem list that indicates the client's current clinical problems for each encounter
-Evaluates and records health status and functional levels using accepted measures
-Documents the clinical reasoning/rationale for diagnoses and conclusions
-Provides a longitudinal or lifetime client record by linking all of the client's data from previous encounters
-Supports confidentiality, privacy, and audit trails
-Provides continuous access to authorized users
-Allows simultaneous and customized views of the client data for individuals, departments, or enterprises
-Supports links to local or remote information resources, such as various databases using the Internet or organization-based intranet resources
-Facilitates clinical problem solving by providing decision analysis tools
-Supports direct entry of client data by physicians
-Includes mechanisms for measuring the cost and quality of care
-Supports existing and evolving clinical needs by being flexible and expandable
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