Patient data is grouped together into an “encounter” and includes the following information:
- Facility characteristics
- Patient characteristics
- ER encounters as admitting source are merged
- Clinical assessments including
- Height / weight / BMI
- Vital signs
- Respiratory
- Clinical characteristics, including key comorbid conditions and selected admission labs
- 1º and 2º diagnoses and procedure codes (ICD-9)
- Supplemental diagnoses and procedures (outside inpatient encounters)
- Inpatient pharmacy orders and dispensing data
- General lab quantitative values with or without microbio and resistance testing results (beyond admission labs)
- SurgiNet (surgical suite) data, where available
- Key outcomes (in-hospital mortality, LOS, total billed charges / estimated costs, 30-day readmission)
- Reimbursement / billing charges
Data Scope:
- EHR-level, detailed clinical information, not just orders or claims
- Longitudinal tracking of patients
- Data time-stamped to minute-wise resolution
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Source: Cerner Health Facts® data
