(radiology, laboratory, etc. ) DSM provides consistent abbreviations for prescription and administrative use. It facilitates psychiatric education and research. Its structure is multi-axial: clinical syndromes, developmental and personality disorders, physical disorder, severity psychological stresses, and global assessment functioning RCS is a comprehensive nomenclature and classification of medical terms for computerized records. UML facilitates the unification of clinical data classification systems into a single unified medical language system. It will also facilitate the creation of data into compatible automated patient record systems. Its structure reconciles clinical terminology, semantics, and formats of the major clinical coding and reference systems Knowledge (e.g, ARDEN SYNTAX The ARDEN SYNTAX is a standard for sharing medical knowledge bases in the form of medical logic modules (MLM). Its structure is derived from the HELP (LDS Hospital)and the CARE (Regenstrief MC)systems. The MLMs accommodate alerts, management critiques, therapy suggestions, diagnosis scoring, etc. Each MLM is limited to the knowledge to make a single decision. HCFA (e. g, UCDS, WARP, UHDDS) UCDS provides an electronic clinical data set that Medicare can use to perform clinical quality reviews. The quality evaluation is done by using algorithms related to surgical procedures, disease specific, organ specific discharge status and disposition, etc. The UCDS permits the hospital to enter the data into a personal computer then this information can be sent electronically to the HCFA. warP provides an epidemiologic approach to quality assurance. It hopes to overcome about 50% of ICD miscoding and its initial focus is on ambulatory chart review rather than real-time patient care. It is not a diagnostic or procedural classification system. It basically provides a model for encoding clinical information. It is an object-oriented case tool. UHDDS was created for studies on quality of care and fraud. It is also used for auditing Medicare and Medicaid subsystems. Bedside Terminals/point-of-Care Systems Patient information is generated on an ongoing basis, wherever the patient may be. Almost two decades ago with the creation of the first programmable calculators, a trend started in terms of calculating hemodynamic variables in the OR, etc. This approach was improved with the creation of personal computers, ending with the development of what are now called bedside terminals. Companies such as Clinicom, Emtek, Hewlett Packard, Hospitronics, and Spacelabs offer systems that can go from doing simply patient monitoring, to a complete data acquisition, data management, and data analysis system that incorporates in some cases diagnosis and treatment therapy. From the patients' point of view, it is critical to integrate their demographic information with their clinical data. Usually the HIS contains all the ADT, orders, laboratory, pharmacy, etc. while the CIS may be more of a departmental system such as ICU/CCU, which contains hemodynamic variables, i. e, blood pressure, stroke volume, heart rate, etc. Both systems need to coexist. Point-of-care systems, many times known as bedside terminals, include both general med/surgery and the ICU/CCU type. The general type include functions such as patient assessment, nursing diagnosis, patient care plans, kardex, discharge planning, discharge summary medication administration record, I/O, vital signs, activities of daily living, patient classification/acuity, etc. The ICU/CCU systems in addition contain information regarding drug administration, fluid analysis, hemodynamic lysis (i.e, blood gas report, ECG, blood pressures, pulse oximeters, cardiac output), respiratory analysi (i.e, ventilator data, O /CO, analyzer), and real-time monitoring. Today's trends are incorporating imaging devices in both at the regular nursing stations, at the operating rooms, and at the recovery room/ICU/CCU. The motivation is to incorporate all patients' information and have it available wherever they may be. As a atient moves from a regular bed to the OR, back to an ICU, and later to a regular nursing station, the electronic record follows the patient. The one big difference with paper charts is that the electronic record can be shared simultaneously within and outside the institution Having the ability to look at electronic images in all of these locations not only opens the doors for consultation within the institution but also with outside institutions and/or expert individuals e 2000 by CRC Press LLC© 2000 by CRC Press LLC (radiology, laboratory, etc.). DSM provides consistent abbreviations for prescription and administrative use. It facilitates psychiatric education and research. Its structure is multi-axial: clinical syndromes, developmental and personality disorders, physical disorder, severity psychological stresses, and global assessment functioning. RCS is a comprehensive nomenclature and classification of medical terms for computerized records. UMLS facilitates the unification of clinical data classification systems into a single unified medical language system. It will also facilitate the creation of data into compatible automated patient record systems. Its structure reconciles clinical terminology, semantics, and formats of the major clinical coding and reference systems. Knowledge (e.g., ARDEN SYNTAX) The ARDEN SYNTAX is a standard for sharing medical knowledge bases in the form of medical logic modules (MLM). Its structure is derived from the HELP (LDS Hospital) and the CARE (Regenstrief MC) systems. The MLMs accommodate alerts, management critiques, therapy suggestions, diagnosis scoring, etc. Each MLM is limited to the knowledge to make a single decision. HCFA (e.g., UCDS, WARP, UHDDS) UCDS provides an electronic clinical data set that Medicare can use to perform clinical quality reviews. The quality evaluation is done by using algorithms related to surgical procedures, disease specific, organ specific, discharge status and disposition, etc. The UCDS permits the hospital to enter the data into a personal computer; then this information can be sent electronically to the HCFA. WARP provides an epidemiologic approach to quality assurance. It hopes to overcome about 50% of ICD miscoding and its initial focus is on ambulatory chart review rather than real-time patient care. It is not a diagnostic or procedural classification system. It basically provides a model for encoding clinical information. It is an object-oriented case tool. UHDDS was created for studies on quality of care and fraud. It is also used for auditing Medicare and Medicaid subsystems. Bedside Terminals/Point-of-Care Systems Patient information is generated on an ongoing basis, wherever the patient may be. Almost two decades ago with the creation of the first programmable calculators, a trend started in terms of calculating hemodynamic variables in the OR, etc. This approach was improved with the creation of personal computers, ending with the development of what are now called bedside terminals. Companies such as Clinicom, Emtek, Hewlett￾Packard, Hospitronics, and Spacelabs offer systems that can go from doing simply patient monitoring, to a complete data acquisition, data management, and data analysis system that incorporates in some cases diagnosis and treatment therapy. From the patients’ point of view, it is critical to integrate their demographic information with their clinical data. Usually the HIS contains all the ADT, orders, laboratory, pharmacy, etc. while the CIS may be more of a departmental system such as ICU/CCU, which contains hemodynamic variables, i.e., blood pressure, stroke volume, heart rate, etc. Both systems need to coexist. Point-of-care systems, many times known as bedside terminals, include both general med/surgery and the ICU/CCU type. The general type include functions such as patient assessment, nursing diagnosis, patient care plans, kardex, discharge planning, discharge summary, medication administration record, I/O, vital signs, activities of daily living, patient classification/acuity, etc. The ICU/CCU systems in addition contain information regarding drug administration, fluid analysis, hemodynamic analysis (i.e., blood gas report, ECG, blood pressures, pulse oximeters, cardiac output), respiratory analysis (i.e., ventilator data, O2/CO2 analyzer), and real-time monitoring. Today’s trends are incorporating imaging devices in both at the regular nursing stations, at the operating rooms, and at the recovery room/ICU/CCU. The motivation is to incorporate all patients’ information and have it available wherever they may be. As a patient moves from a regular bed to the OR, back to an ICU, and later to a regular nursing station, the electronic record follows the patient. The one big difference with paper charts is that the electronic record can be shared simultaneously within and outside the institution. Having the ability to look at electronic images in all of these locations not only opens the doors for consultation within the institution but also with outside institutions and/or expert individuals