Electronic Medical Record (Electronic Medical Record, EMR) is a medical software, the hospital through the electronic medical record to electronically record the information of the patient's visit, which includes: the first page, the course of the record, the test results, the doctor's orders, surgical records, nursing care records, etc., which are both structured information, as well as unstructured free text, and graphic information. It also has unstructured free text and graphic information. It involves the collection, storage, transmission, quality control, statistics and utilization of patient information. Serves as a primary source of information in healthcare, providing services beyond paper medical records to meet medical, legal, and administrative needs.
[Edit Paragraph]Usage
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 regulations, on the other hand, it 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 individual to 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. It will improve the rate of medical records, and thus improve the overall competitiveness of the hospital.
Second, 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 efficiency and medical level.
Third, to improve the quality of the case
The electronic medical record system provides 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.
Fourth, improve the ability to prove medical disputes
Medical records are legally valid medical records, for medical malpractice appraisal, medical dispute disputes to provide legal evidence of the facts of the medical act, such as when encountering legal disputes, the absence of written content is regarded as the absence of questioning, checking, then the court will be considered as negligence, which will cause 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 hospitals and medical staff, but also on the hospital's 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 be unclear, 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 Book" fundamentally solves the above problems.
Seventh, 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, retrieve statistics through the electronic medical record system can not only quickly retrieve the required variety of medical records, and make the previous laborious and laborious medical statistics has 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 domestic hospitals of the traditional management mode and the actual needs, the development of 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 that is 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 easy to use.
☆ Support for the structured storage of medical record documents, is a real structured electronic medical record system.
☆ Support for a rich library of medical record templates (simple element library, complex element library, small template library, large template library, common language library).
☆ Medical record large templates distinguish between male and female patients.
☆ Provide medical-specific input method, provide medical-specific words and phrases.
☆ Supports continuous printing (continuation), repeated 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 into 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 to prohibit deletion.
☆ Support for key text deletion (e.g., key text 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.
☆ Support for various medical-specific expressions (e.g., formula expressions 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.
☆ Support for three levels of medical record document examination (three levels of audit) function.
☆ Support for the retention of traces of changes, to retain the traces of changes at all levels of doctors.
☆ Support for data locking, sign-in, sign-out mechanism.
☆ Introduces the time control mechanism, adopts the workflow master push mode, the task automatically prompts, timely reminds and urges the medical staff, on time, according to the quality, according to the quantity to complete the work of medical record writing, 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.
☆ Support for structured retrieval of electronic medical records.
☆ Support for offline writing of medical records.
☆ Support the extraction, storage and retrieval of typical medical records.
☆ Support for automatic scoring of medical records.
☆ Support for online borrowing and approval of medical records.
☆ Fast copy function.
☆ Support for attaching various multimedia files (e.g., sound, images, video, animation, etc.) to documents as attachments.
☆ The medical record document can be exported in XML format for easy data exchange.
☆ Support for wireless handheld devices such as PDAs.
☆ Supports seamless access to HIS, PACS, LIS, RIS, and other systems.
☆ Provide operation security, data transmission security, data storage security.
☆ Medical record document compression and encryption storage, greatly saving storage space.
☆ Support the entry and printing of three test orders.
[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) Symptomatic information
(3) Physical sign information
(4) Laboratory examination 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 workers, and the basic conditions for structured data entry are structured system models, knowledge-driven content, predefined vocabularies, and synthetic expression rules.
② Structured data entry methods
(2) Natural language data entry. (NLP)
The advantage of NLP is that physicians do not have to change the way they are used to 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 for the terms used, and these indexes can extract text containing one or more and specified terms, which NLP will be able to link and process for inference.
(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 these digitized medical information can be integrated into the electronic medical record through the interface of the system.
The transfer of information between different systems is through system interfaces, and information standardization is the key to interfaces. 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 can be understood by the system receiving the information, 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
The medical record is a document with legal effect, and the medical record 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 the contents of the medical record, the system will automatically delete the contents of the red and in the middle of the text to add a horizontal line; if it is the director of the medical record to delete or add the contents of the medical record, the system automatically deleted the contents of the red and in the text of the middle of the two horizontal lines, to the new added content of the red and in the middle of the text to 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
The production of the case
Briefly describe the electronic medical
(1) electronic case template header, footer, the production of the main points
(1) electronic case templates, headers and footers, production points
Using Word as a template, the system will automatically delete the content or add the content of red and add two horizontal lines under the text. >
Using Word 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.
① Header commonly used format for "name, department, bed number, case number". Some hospitals will be "medical records", "medical records", "paper" 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 the wrong line.
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 the page number, generally should be based on the requirements of each hospital to design.
(2) electronic case template content design points
① admission record template content should include "general items, complaints, history of the current disease" 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, the 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 are listed together after the case of writing the entire sequence of the process routing in the case template.
[Edit]Notes on the use of
(1) must do a good job of the initial set of system data
(2) strict security management
(3) tightly organized data switching
(4) to ensure that the organization of the coordination between each other
(5) to strengthen the confidentiality of medical staff security education
(6) (6) Strict medical advice checking system
(7) Standardization of electronic case templates
(8) Strengthening of management and monitoring