# Glossary

Consults

Consu lt/Request Tracking is a component or package of the CPRS (it can function as part of CPRS or independently as a standalone package or as part of TIU). A consult or consultation is a r eferral of a patient by the primary care physician to anot her hospital service/specialty, to obtain a medical opinion based on patient evaluation and completion of any procedures, modalities, or treatments the consulting specialist deems necessary to render a medical opinion.

CPRS

Computerized Patient Record Sy stem, the DHCP package (in both GUI and character-based formats) that provides access to most components of the patient chart.

CWAD

Crises, Warnings, Allergies, and (Advanced) Directives. Also called "postings", these notes provide important information a bout a patient, such as a "Do Not Resuscitate" order or known allergies. In the CPRS GUI, the CWAD button is on the upper right. If a patient has only Warnings, a "W" will appear on the button. Each letter will appear only if a note exists in that categor y.

D/C Summaries

See Discharge Summary.

Discharge Summary

A component or package of CPRS (it can function as part of CPRS or independently as a standalone package or as part of TIU). A Discharge Summary is a summary of a patient's record of care, required at time of discharge.

Encounter

A visit (or telephone call) with a health care provider. All outpatient visits requ ire encounter data, including service connection, a provider name, a procedure, and a diagnosis, to receive workload credit. Health care workers will be prompted for encounter information when they enter clinically relevant information. Encounter informat i on also helps track who gave what orders for patient care.

GUI

Graphical User Interface, the Windows-like screen with pull-down menus, icons, pointer device, etc.

Imaging

Imaging is the name of the umbrella package that includes Radiology and Nuclear Med icine. Tests and procedures for these packages can be ordered, results can be viewed, and reports can be generated through CPRS.

OE/RR

Order Entry/Results Reporting, a V IST A program that evolved into the more comprehensive CPRS.

Postings

Messages about a patient, similar to CWAD, but more extensive.

Progress Notes

A progress note is a health provider's recorded observations about a patient at the time of an encounter (inpatient or outpatient). Progress Notes can function as part of CPRS and also as part of TIU to let users enter, edit, sign, review, and print online progress notes through either program. At this time, if users want to enter, edit, review, or sign notes for multiple patients, they must go through the TIU interface.

TIU

Text Integration Utilities; a package for document handling, that includes Consults, Discharge Summary, and Progress Notes, and will later add other document types such as surgical pathology reports. TIU components can be accessed for individ ual patients through the CPRS, or for multiple patients through the TIU interface.

V IST A

Veterans Health Information Systems Technology and Architecture, the organization and program formerly called DHCP.