2.2.5 Patient data

During a patient's hospital stay, various information is collected about a patient. Demographics, vital signs, laboratory tests, medications, fluid balance, nursing notes, imaging reports, etc. can all be recorded in the database.

• Demographics: When a patient is admitted to the hospital, their demographic information is recorded. Marital status, ethnic origin, religion and insurance status are recorded.
• Medication records: Medications prescribed and administered either via computer controlled iv or oral. Computer controlled administration via iv is automatically administered. Although manual prescription is recorded for pharmacy orders, there is no guarantee that the medication was actually administered to the patient.
• Fluid records: Fluids withdrawn/administered from/to a patient are also recorded. This provides physicians with an up-to-date and accurate measure of a patient's fluid levels.
• Notes: MD Notes (for neonates), nursing notes and discharge summaries are recorded in free-text fields in the database. Nurses can enter any information here. ECG, echo and radiology reports are also available.
• Chart: A patients medical chart contain any parameters recorded by the staff: validated physiologic recordings, demographic information, weight, height and ventilator settings are examples of the type of information recorded here.
• Laboratory tests: Results of blood gas, chemistry and other body fluid tests are recorded here.