[edit]Uses
I. Improvement of Class A medical record qualification rate
Improvement of Class A medical record qualification rate, on the one hand, needs to be ensured through various management means as well as rules and regulations, and on the other hand, needs to be combined with a variety of new technologies, through feasible technological pathways to integrate a variety of resources, clearly implement the responsibilities to the specific individuals, and improve the hospital's management of the quality of the medical case Through statistics, analysis, early warning, three-level quality assessment and other means of prior control, medical staff can be effectively reminded and urged to complete the writing of medical records on time and in accordance with quality. Improve the rate of grade A medical records, thereby improving the hospital to provide comprehensive competitiveness.
Two, for the medical staff to save a lot of time, better for the hospital and patient services
For doctors, every day to receive and treat a number of patients, 70% of the time in the day-to-day work due to manual writing of medical records. Through the electronic medical record system provides a variety of standardized templates and auxiliary tools, not only can the medical staff from the tedious repetition of medical record paperwork to free up, focus on the patient's diagnosis and treatment, and through the template written by the medical record is more complete, standardized, and, at the same time, will also enable the doctor to spend more time to improve their own business level, to admit and treat more patients, which can improve the hospital's economic benefits and medical standards.
Three, improve the quality of the case
Electronic medical record system by providing a complete, authoritative, standardized, rigorous medical record template, to avoid writing scribbles, missing pages, omissions, fuzzy and non-standard terminology and other common problems, to improve the rate of audit of the medical record to improve the hospital to provide comprehensive competitiveness.
Four, improve the ability to prove medical disputes
Medical records are medical records with legal effect, for medical malpractice appraisal, medical dispute disputes to provide legal evidence of the facts of medical behavior, such as when encountering legal disputes, the content of the absence of writing is regarded as no questioning, checking, then the court will be regarded as negligence, which will be a great deal of passive hospitals, and even losses. By conforming to the standardized medical record, it avoids the problems of semantic ambiguity, scribbling, missing pages, omissions, etc., and reduces the possible but avoidable errors that will adversely affect all aspects of the hospital, and provides a strong legal basis for the reversal of the burden of proof. Not only safeguard the legitimate rights and interests of the hospital and medical staff, but also the hospital reputation, economic benefits can bring benefits.
V. Stabilize and expand the source of patients
The electronic medical record system provides patients with long-term health records and supports rapid retrieval of health records, providing more historical reference materials for medical staff to make decisions and improve patient recognition of the hospital.
Sixth, improve the standardization of medical records
The content of paper medical records is in the form of free text, the handwriting may not be clear, the content may be incomplete, the meaning may be vague. Transcription is prone to potential errors. It can only be passively used by doctors as a reference for decision-making, and cannot realize active reminders, warnings or suggestions. The phenomenon of alteration is prominent, the writing of medical history is arbitrary, the computer printout of medical records is not properly copied, resulting in the phenomenon of "Zhang Guan Li Dai", the lack of a certain record of the contents of the medical record, and the completion of the medical record is not timely. The electronic medical record system of "Medical Record Dictionary" fundamentally solves the above problems.
Seven, scientific research, teaching and statistical analysis to provide first-hand valuable information
In medical statistics, scientific research, typical medical records are not easy to screen, difficult to retrieve statistics through the electronic medical record system can not only quickly retrieve the required variety of medical records, and make the previous laborious medical statistics become very simple and fast, for scientific research and teaching to provide first-hand information.
[Edit Paragraph]Main Functions
In order to meet the needs of the development of China's hospitals, in order to make the motherland's medical science and technology in line with the world as soon as possible, Dalian Huiyuan Electronic System Engineering Co., Ltd. focused on a large number of manpower and material resources, drawing on the domestic and international HIS advanced experience, and combined with the traditional management mode of the hospitals in the country and the actual needs of the hospitals, the development of the hospital management information system, and the hospital management information system, and the hospital management information system. In 2001, Huiyuan Hospital Management Information System was recognized as a software product by Dalian Information Industry Bureau, which is a hospital management information system really suitable for China's national conditions, and is the only hospital information system with independent intellectual property rights that can share the world with IBM's hospital information system solutions in China. ☆ WYSIWYG interface style, intuitive and simple, easy to learn and use.
☆☆Supports the structured storage of medical record documents, which is a real structured electronic medical record system.
☆Supports rich medical record template libraries (simple element library, complex element library, small template library, large template library, and common language library).
☆The large template of medical records distinguishes between male and female patients.
☆Provides medical-specific input method, providing medical-specific words and phrases.
☆Supports continuous printing (continuation), repetitive printing, and printing by page number for medical and nursing records.
☆☆Powerful form processing capabilities (you can easily create a form medical records), support for table nesting, merge cells, split cells, delete rows, delete columns, add rows, add columns, insert elements in the table, table width manual or automatic adjustment.
☆☆Support for data element binding, the realization of the multi-document synchronization refresh technology.
☆Support for key text deletion. (e.g., key words such as "chief complaint, current medical history, past history, family history, general examination, specialized examination").
☆Support input value legitimacy check.
☆Supports checking of required fields.
☆Supports various medical-specific expressions (e.g., formulas for menstrual history, fetal heart, and caries location).
☆☆Rich medical image library and powerful medical loss map editor, support graphics multiple editing, combining, splitting, Undo/Redo, complex fill, custom line, copy, paste and other complex operations.
☆☆Three levels of medical record documentation (three levels of review) support.
☆Supports the retention of modification traces, preserving the traces of modifications made by doctors at all levels.
☆Supports data locking, check-in and check-out mechanisms.
☆Introduces time control mechanism, adopts workflow push mode, automatic task prompting, timely reminding and urging medical staff to complete the medical record writing work on time, in accordance with the quality and quantity, and effectively avoids the lack of writing, omission of writing, and delayed writing of the medical record document.
☆Introducing a messaging mechanism to monitor the whole process of medical record writing in real time.
☆Supports structured retrieval of electronic medical records.
☆Supports offline writing of medical records.
☆Supports the extraction, storage and retrieval of typical medical records.
☆Supports automatic scoring and evaluation of medical record quality.
☆Supports online borrowing and approval of medical records.
☆Rapid copy function.
☆Support for attaching multimedia files (e.g., sound, image, video, animation, etc.) as attachments to documents.
☆☆Export medical record documents in XML format for easy data exchange.
☆Supports wireless handheld devices such as PDAs.
☆Supports seamless access to HIS, PACS, LIS, RIS, and other systems.
☆Provides operation security, data transmission security, and data storage security.
☆Compressed and encrypted storage of medical record documents, greatly saving storage space.
☆Supports the entry and printing of the three test sheets.
[Edit paragraph]Features
(1) Standardize the writing of cases, improve the quality of cases, and realize the standardization of cases.
(2) Fast transmission speed.
(3) *** Enjoyment is good.
(4) Large storage capacity.
(5) Easy to use.
(6) Low cost.
[edit]Component elements and categorization
Component elements:(1) Basic information
(2) Diagnostic information
Categorization:(1) Patient's general information
(2) Symptom information
(3) Signs and symptoms
(4) Laboratory test information
(5) Diagnostic information
(6) Treatment information
(7) Disease regression information
(8) Cost information
(9) Healthcare worker information
[edit]Data entry methods
(1) Entry of structured data.
① Basic conditions for structured data entry
A large amount of information in the case can be directly structured data entry by healthcare professionals, and the basic conditions for structured data entry are structured system model, knowledge-driven content, predefined vocabulary lists, and rules for synthetic expressions.
②Structured data entry methods
(2) Natural language data entry. (NLP)
The advantage of NLP is that physicians do not have to change their accustomed way of recording when writing cases, and are free to express a variety of information. They can use handwritten text or tape recordings. For recordings, NLP systems can use speech recognition systems to analyze sentences in natural language and process the medical information contained in them for data entry.The most basic function of NLP is to generate indexes of the terms used, and these indexes can extract text containing one or more and specified terms, which NLP will be able to process in connection with each other to make inferences.
(3) Bio-signal and Medical Image Processing
With the introduction of a large number of digitized instruments and equipment in hospitals and the application of medical information systems such as LIS, PACS, etc., bio-signals and medical images have been gradually digitized through their processing and can be integrated into the electronic medical record by using the system's interfaces to integrate these digitized medical information.
The transfer of information between different systems is through the interface of the system, and information standardization is the key to the interface. When two systems use the same standard, transferring information is very simple. If the two systems are not using the same standard, the interface must convert the information, either by the system sending the information through the interface to convert the data into a format that the system receiving the information can understand, or by the receiving system through the interface to convert the data into a format that can be understood. The standardization of information is a gradual process, and in order to facilitate interfaces between systems that use non-standard information, interface engines have been developed that use interface engines to convert non-standardized information into standardized information.
(4) Signature and change of electronic medical records
Medical records are documents with legal effect, and medical data has the role of legal evidence. The security of medical data in the medical record is extremely important, which not only maintains the interests of patients, but also maintains the interests of medical personnel. Every time you write an electronic medical record, you have to sign it before it takes effect. If you re-open the electronic medical record to change the operation, the EPR system will carry out different processing for different change of people, such as the previous level of physicians to delete or add content to the medical record, the system will automatically delete the content of the red and add a horizontal line in the middle of the text; if it is the director of the doctor to delete or add content to the medical record, the system will automatically delete the content of the red and add two horizontal lines in the middle of the text, and the new added content of the red and add two The system automatically turns the deleted content red and adds two horizontal lines in the middle of the text, and turns the newly added content red and adds two horizontal lines under the text.
[edit]Template format
(1) paper size
(2) page setup
(3) layout requirements
(4) case paper style
case of the production of the method
Briefly described the electronic patient
(1) electronic case template in the header, footer, the production of the main points
With Word as a template, the system will automatically delete the content or add content, the system will automatically delete the content of the red and add two horizontal lines under the new content red and text. >
Word is used as an editor to create a medical record template, the medical record template should be in line with the "Medical and Nursing Technology Operation Routine" in the fourth edition of the writing requirements of the case.
①The common format of the header is "name, department, bed number, case number". Some hospitals will be "continued", "medical records", "medical records" and so on are also included, there is no uniform regulations. In order to enter the actual content of the header content does not move back and forth, the header must establish a form, the name, department, bed number, case number box in which, leaving the appropriate space, the doctor will write the patient's name and other content in which the patient can be filled in. Be careful to leave enough space to avoid wrong lines.
② form settings to use Word to provide a form of automatic application of the grid format, so that the print out does not show the structure of the form, so that the medical record is beautiful and generous. In the design of the medical record in the form of an input line below can not be deleted, so that the header and the content of the medical record to maintain the appropriate space between.
3 footer should include the name of the hospital and page number, generally should be based on the requirements of each hospital to design.
(2) electronic case template content design points
①Admission record template content should include "general items, the main complaint, the current history" and so on. The beginning of the case for the "admission record", below it for a table, the first six items for a column, and leave a column corresponding to it. In the form of four columns and six rows of the design. With the word provided by the form automatically apply the grid format, adjust the appropriate column width, so that the column width has enough space to enter the contents of the project. This production project is neatly arranged, input content will not move wrongly.
② will be the main complaint, the current medical history, personal history, family history, physical examination and other items listed together after the case of writing the entire sequence of process routing in the case template.
[Editorial]Notes on the use of
(1) must do a good job of the initial set of system data
(2) strict security management
(3) strict organization of data switching
(4) to ensure that the organization of the coordination between each other
(5) to strengthen the confidentiality of the medical staff security education
(6) Strictly checking the system of medical advice
(7) Standardization of electronic case templates
(8) Strengthening management monitoring