Patient Safety: Achieving a New Standard for Care (2004)
Chapter: Appendix D: Clinical Domains for Patient Safety
D
Clinical Domains for Patient Safety
Consolidated Health Informatics Initiative Clinical Domain Areas | Additional Domains for Patient Safety |
Demographics |
|
Diagnosis/problem lists for: Signs Symptoms Diseases Social problems | Patient risk factors/precursors (e.g., designation of comorbid diagnosis) |
Interventions/procedures including: Laboratory orders Laboratory results contents | Complications associated with specific procedures |
Encounters | Episodes |
| Process-specific risk factors (e.g., managing coronary health failure) |
| Departmental risk factors (e.g., delays in the emergency room) |
| Clinical data measures for health conditions |
Medications including: Clinical drugs Warnings | Alternative medicines Nutritional supplements Vitamins |
Consolidated Health Informatics Initiative Clinical Domain Areas | Additional Domains for Patient Safety |
Allergic reactions Adverse drug events (ADE) | Over-the-counter medications Previous known adverse drug reactions Triggers Medication orders Drug interactions Patient-specific drug dosing Diagnosis-specific drug indications Diagnosis-specific drug contraindications |
Text-based reports including: Clinical document architecture Clinical document naming | Clinical template |
History and physical including: History Vital signs Anatomy Exam findings Functional status | Nutritional status Discharge or treatment plan Determinants for genetic testing/screening of family-related diseases |
Immunizations |
|
| Provider information Training level, cultural factors, speaking language, health |
Population health including: Nosocomial infections reporting Reportable infections reporting Other reportable conditions Hospital errors other than ADE Emergency room trauma reporting Other national health statistics | Near misses Patient complaints Readmission indicators Performance measurement Causal factors Malpractice claims Risk management reports Potential adverse events assessment through electronic surveillance |
Genes and proteins | Pharmacogenomic markers for drug response or drug complication |
Multimedia including but not limited to: Image Audio Waveforms |
|
Consolidated Health Informatics Initiative Clinical Domain Areas | Additional Domains for Patient Safety |
Nursing including: Diagnoses Interventions Goals and outcomes | Process-specific nursing factors Acuity levels for nurse staffing |
Physiology |
|
| Knowledge bases (systematic reviews of): Clinical guidelines Medical literature Health outcomes data Disease registries |
| Patient self-management Data set and guidelines for self-care Rx interaction program access |
Functioning and disability | Rehabilitation therapies Respiratory Occupational Speech, etc. |
Supplies including: Ontology for the ordering physician Medical devices | Medical device simulations and testing |
| Organizational process factors Organizational risk factors Hazard analysis |
Chemicals (Unified Medical Language System—UMLS) |
|
Billing (Health Insurance Portability and Accountability Act, Administrative Simplification, Transactions and Code Sets) | Data from claims attachment |
Scientific/fundamental (UMLS) |
|
Units (UMLS) |
