CONO Clinical Sciences cheat sheet
CONO Clinical Sciences · Keep the key ideas within reach.
Documentation, Informatics, and Health Information Management
A complete clinical note records date and time, author, history, examination findings, assessment, plan, and patient response to therapy.
Problem-oriented records link each problem to its own progress notes, orders, and resolved status.
Computerized provider order entry with clinical decision support reduces medication errors, especially dosing and allergy checks.
Meaningful-use and interoperability standards (HL7, FHIR) govern exchange of structured data between systems.
Protected health information is governed by minimum-necessary and patient-access rules; audit trails record who accessed what and when.
Copy-forward and template overdocumentation create note bloat and propagate errors; each entry must reflect the current encounter.
Late entries are labeled as such with the actual entry time and reason, preserving the original record's integrity.
Data quality dimensions are accuracy, completeness, timeliness, consistency, and validity; each is audited separately.
Clinical decision support alerts suffer from alert fatigue; sensitivity and specificity of alerts must be tuned to preserve clinician response.