NDMS Electronic Medical Records
NDMS Electronic Medical Records
NDMS Electronic Medical Records
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Future Direction<br />
Item On-site Care Emergency Care<br />
Record<br />
Pain Status<br />
• Level (1-10)<br />
Treatment History - examples may include:<br />
• Last two episodes of care for the chief complaint<br />
• Last five episodes of care<br />
<strong>NDMS</strong> EMR<br />
X X X*<br />
Captured in ROS<br />
and PE<br />
X X*<br />
Self Reported<br />
Present Episode - examples may include:<br />
• Complaint(s)<br />
• Vital signs<br />
• Visual assessment<br />
• Medications administered<br />
Patient Location - examples may include:<br />
• Location of incident<br />
• Current location<br />
• Receiving facility location<br />
• Date/time of arrival<br />
Triage Category - examples may include:<br />
• Delayed<br />
• Immediate<br />
• Minimal<br />
• Expectant<br />
Advance Directive Status - examples may include:<br />
• Living will<br />
• Do not resuscitate orders<br />
• <strong>Medical</strong> power of attorney<br />
X X X<br />
X X X<br />
X X X<br />
X<br />
Not currently<br />
captured.<br />
<strong>NDMS</strong> Internal Use Only 23
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