Clinical info Matrix

On November 01, 2005 Available in:	ORCA ⁽¹⁾	MINDscape ⁽²⁾	CIS⁽³⁾	Paper
HMC	Includes Inpatient/Outpatient	Includes Inpatient/Outpatient	Inpatient	If initiated during current encounter Inpatient/Outpatient	Where to look first for current data
Advanced Directive	˜scanned			˜	ORCA or Paper
Alerts--Clinical Alerts/CROS Reminders	˜ scanned, dictated	˜			ORCA or MINDscape
Alerts--Caution/Admin Alerts	˜	˜	˜		ORCA, MINDscape or CIS
Allergies	˜primary source	˜	˜	˜MDS	ORCA
Anatomic pathology results	˜	˜			ORCA, MINDscape
Anesthesia Record	˜scanned			˜	ORCA
Cardiac Catheterization Reports	˜	˜		˜	ORCA
Clinic Appointment/Schedules (view only)	˜	˜			MINDscape
Clinic Notes	˜scanned, dictated or direct entry	˜if dictated or ORCA direct entry		˜	ORCA
Consent for Care	˜			˜	ORCA or Paper
Consult requests	˜			˜	ORCA or Paper
Consult notes	˜	˜if dictated or ORCA direct entry		˜	ORCA or Paper
Correspondence	˜	˜		˜	ORCA
Discharge Instructions - ED	˜			˜	ORCA or Paper
Discharge Report, Interdisciplinary	˜		˜		ORCA or CIS
Discharge Summary	˜	˜			ORCA
Echocardiogram Reports	˜scanned	˜		˜	ORCA, MINDscape
EEG Report	˜scanned	˜		˜	ORCA, MINDscape
EKG Rhythm and report	˜scanned	˜		˜	ORCA, MINDscape
EMG Report	˜scanned	˜		˜	ORCA, MINDscape
Graphical display of physiological data			˜	˜	CIS
Hematopathology	˜scanned	˜			ORCA, MINDscape
History and Physical - inpatient	˜scanned or direct entry	˜	˜	˜	Paper or CIS
History and Physical - SCCA inpatient		˜			MINDscape
Immunizations	˜scanned (flowsheets/notes) direct entry notes	˜	˜	˜	ORCA, MINDscape, CIS, or Paper
Initial physician assessment - outpatient	˜scanned, dictated or direct entry	˜if dictated or ORCA direct entry		˜	ORCA, MINDscape, or Paper
IV Drips: ambulatory			˜	˜	Paper
IV Drips: inpatient			˜	˜	CIS
Lab Results (chem, heme, micro)	˜2002-present	˜	˜		ORCA
Labs, Graphical Display	˜	˜			ORCA

Medication Administration Record			˜	˜	CIS or Paper
Medication List: Inpatient	˜		˜	˜	CIS or Paper
Medication List: Procedure Meds	˜		˜	˜	CIS or Paper
Medication list - Outpatient (Retail)	˜scanned	˜		˜MDS	ORCA MINDscape or Paper
Nursing Documentation: Patient History, Assessment, I/0; treatments; outcomes;pain management, notes; plan of care, weight, etc	˜scanned, outpatient direct entry	˜ if outpatient ORCA direct entry (healthlinks)	˜	˜	CIS or Paper
Nutrition notes/ Documentation	˜	˜ if outpatient ORCA direct entry	˜	˜	ORCA or CIS or Paper
Operative Report--dictated	˜	˜			ORCA
Orders	˜scanned			Order book	ORCA or Paper
Outside medical records	˜			˜	ORCA or Paper
Patient Education - including HealthLinks	˜scanned or outpatient direct entry	˜ outpatient ORCA direct note entry	˜	˜	ORCA or CIS or Paper or Mindscape
Patient Problem List		˜	˜	˜ MDS	MINDscape, CIS, or Paper
Perinatal Information	˜	˜		˜	MINDscape or Paper
Physical/occupational therapy notes	˜	˜if ORCA direct entry	˜	˜	CIS or Paper
Procedure List		˜			MINDscape
Procedure Reports	˜	˜		˜	MINDscape or Paper
Progress notes, inpatient: varies by team member; service, and care area	˜	˜if Flexnote⁽⁴⁾	˜	˜	Paper, CIS, or MINDscape
Pulmonary Function Tests	˜scanned	˜		˜	MINDscape or Paper
Radiology reports	˜	˜			ORCA
Final CT, MR, standard radiography	˜	˜		˜	ORCA
Preliminary CT, MR, standard radiography	˜	˜		˜	ORCA
Preliminary invasive radiology	˜	˜		˜	Paper
Preliminary vascular studies	˜scanned			˜	Paper
Radiology Images		˜			(PACS)
Rehab therapies, PT/OT notes	˜	˜if ORCA direct entry	˜	˜	ORCA or CIS or Paper or Mindscape
Respiratory Care notes/documentation	˜		˜	˜	ORCA or CIS or Paper
Signout information		˜(CORES)		˜	CORES or Paper
Social work notes/documentation	˜	˜if ORCA direct entry	˜	˜	ORCA or CIS or Paper
Surgery Schedule		˜		˜	MINDscape
Transcription	˜	˜			ORCA
Vital signs	˜ outpt in notes	˜if dictated or ORCA direct note entry	˜	˜	ORCA or CIS or Paper


(1) ORCA--Online Record of Clinical Activity--inbox, pt lists, results for lab, radiology,pathology, inpatient medication lists, transcribed documents, electronic signature transcribed documents; also scanned, & directly entered notes
(2) MINDscape--legacy system for results reporting, problem and procedure lists
(3) CIS--Clinical Information System--documentation by most inpatient disciplines; units not using CIS are UWMC Psychiatry, MICC, Neonatal ICU
(4) Flexnotes--Documents entered into and viewable ONLY in Mindscape