The electronic medical record system (Electronic Medical Record, EMR) is a medical-specific software. The hospital electronically records patient information through electronic medical records. It includes: homepage, disease course records, examination results, and doctor's orders. , surgical records, nursing records, etc., which contain both structured information, unstructured free text, and graphic image information. Involves the collection, storage, transmission, quality control, statistics and utilization of patient information. Serves as the primary source of information in healthcare, providing services beyond paper medical records to meet medical, legal and administrative needs.
[Edit this paragraph] Purpose
1. Improving the pass rate of Class A medical records
To improve the pass rate of Class A medical records, on the one hand, various management methods are needed and rules and regulations to ensure this. On the other hand, it is necessary to combine various new technologies, integrate various resources through feasible technical means, clearly assign responsibilities to specific individuals, and improve the hospital's ability to manage the quality of medical records through statistics, analysis, and early warning. , three-level quality assessment and other prior control methods can effectively remind and urge medical staff to complete medical record writing work on time and according to quality. Improve the Grade A rate of medical records, thereby improving the overall competitiveness of the hospital.
2. Save a lot of time for medical staff and better serve the hospital and patients
For doctors, they have to treat multiple patients every day, and 70 % of the time is due to manually writing medical records. Through the various standardized templates and auxiliary tools provided by the electronic medical record system, not only can medical staff be freed from the tedious and repetitive work of writing medical records and focus on patient diagnosis and treatment, but the medical records written through templates are more complete and standardized. At the same time, it also allows doctors to spend more time improving their professional skills and treating more patients, thereby improving the hospital's economic benefits and medical standards.
3. Improve the quality of medical records
The electronic medical record system avoids illegible writing, missing pages, missing items, vagueness and incompleteness by providing a complete, authoritative, standardized and rigorous medical record template. Standardize terminology and other common issues, improve the medical record review pass rate, and improve the overall competitiveness of the hospital.
4. Improve the ability to provide evidence in medical disputes
Medical records are legally binding medical records that provide legal documentary evidence of medical behavior facts for medical accident identification and medical disputes. During a dispute, if the lack of written content is deemed as a lack of inquiry or inspection, then the court will regard it as a negligence, which will cause great passiveness and even losses to the hospital. Through standardized medical records, problems such as ambiguous semantics, illegible writing, missing pages, and missing items are avoided, and avoidable errors that may have adverse effects on all aspects of the hospital are reduced, providing a strong basis for evidence reversal. Legal basis. It not only safeguards the legitimate rights and interests of the hospital and medical staff, but also brings benefits to the hospital's reputation and economic benefits.
5. Stabilize and expand the source of disease
The electronic medical record system provides long-term health records for patients, supports rapid retrieval of health records, and provides more historical references for medical staff to make decisions. Improve patients' recognition of the hospital.
6. 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, and the meaning may be vague. Transcription is prone to potential errors. It can only passively serve as a reference for doctors to make decisions, and cannot provide active reminders, warnings or suggestions. The phenomenon of erasure is prominent, the writing of medical history is arbitrary, and improper copying of computer-printed medical records results in the phenomenon of "taking one's crown and leaving one behind". Certain medical record records are missing, and medical record records are not completed in a timely manner. The "Medical Records Collection" electronic medical record system fundamentally solves the above problems.
7. Scientific research, teaching and statistical analysis provide first-hand valuable information
In terms of medical statistics and scientific research, it is difficult to screen typical medical records and it is difficult to retrieve statistics through the electronic medical record system. Not only can various required medical records be quickly retrieved, but also the previously laborious medical statistics have become very simple and fast, providing first-hand information for scientific research and teaching.
[Edit this paragraph] Main functions
In order to meet the needs of the development of our country's hospitals and to bring the motherland's medicine into line with world science and technology as soon as possible, Dalian Huiyuan Electronic System Engineering Co., Ltd. has concentrated a large number of Manpower and material resources, drawing on the advanced experience of HIS at home and abroad, and combining the traditional management models and actual needs of domestic hospitals, developed the hospital management information system. In 2001, the "Huiyuan Hospital Management Information System" was recognized by the Dalian Information Industry Bureau As a software product, this product is a hospital management information system that is truly suitable for my country's national conditions. It is the only hospital information system with independent intellectual property rights that can share the world equally with IBM hospital information system solutions in China. ☆What you see is what you get interface style, intuitive and simple, easy to learn and use.
☆ It supports structured storage of medical record documents and is a truly structured electronic medical record system.
☆ Supports a rich medical record template library (simple element library, complex element library, small template library, large template library, and commonly used phrase library).
☆The large medical record template distinguishes between male and female patients.
☆ Provides medical-specific input methods and medical-specific phrases and phrases.
☆Supports continuous printing (continuous printing), repeated printing, and page number printing of disease history records and nursing records.
☆Powerful table processing capabilities (can easily create table medical records), supports table nesting, merging cells, splitting cells, deleting rows, deleting columns, adding rows, adding columns, within tables Insert elements and adjust table width manually or automatically.
☆Supports data element binding and implements multi-document synchronization refresh technology.
☆ Supports prohibiting deletion of key text. (For example, key words such as "chief complaint, history of current illness, past history, family history, general examination, specialist examination").
☆Supports input value validity check.
☆Supports required field check.
☆Supports various medical-specific expressions (such as formula expressions for menstrual history, fetal heart rate, and dental caries location).
☆ Rich medical picture library and powerful medical quantification diagram editor, supporting multiple graphics editing, combination, splitting, Undo/Redo, complex filling, custom line type, copy, paste, etc. Complex operations.
☆Supports the third-level inspection (third-level review) function of medical record documents.
☆Supports the retention of modification traces and retains the modification traces of doctors at all levels.
☆Supports data locking, check-in, and check-out mechanisms.
☆Introduce a timeliness control mechanism, adopt workflow-driven mode, automatically prompt tasks, promptly remind and urge medical staff to complete medical record writing work on time, quality and quantity, effectively avoiding the lack of writing of medical record documents , missed writing, delayed writing.
☆Introduce a message mechanism to monitor the entire medical record writing process in real time.
☆Support structured retrieval of electronic medical records.
☆Support offline writing of medical records.
☆Supports 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.
☆Quick copy function.
☆ Supports attaching various multimedia files (such as sounds, images, videos, animations, etc.) as attachments to documents.
☆Medical record documents can be exported in XML format to facilitate data exchange.
☆Supports wireless handheld devices such as PDAs.
☆Support seamless access to HIS, PACS, LIS, RIS and other systems.
☆Provide operation security, data transmission security, and data storage security.
☆Medical record documents are compressed and encrypted for storage, greatly saving storage space.
☆Supports entry and printing of three test orders.
[Edit this paragraph] Features
(1) Standardize case writing, improve case quality, and achieve case standardization.
(2) Fast transmission speed.
(3) Enjoyment is good.
(4) Large storage capacity.
(5) Easy to use.
(6) Low cost.
[Edit this paragraph] Component elements and classification
Component elements: (1) Basic information
(2) Diagnosis and treatment information
Category: (1) General information of the patient
(2) Symptom information
(3) Sign information
(4) Laboratory test information
p>(5) Diagnosis information
(6) Treatment information
(7) Disease outcome information
(8) Cost information
p>(9) Medical staff information
[Edit this paragraph] Data input method
(1) Entry of structured data.
① Basic conditions for structured data input
A large amount of information in the case can be directly input into structured data by medical staff, and the basic condition for structured data input is a structured system Models, knowledge-driven content, predefined vocabularies, composition expression rules.
②Structured data entry method
(2) Entry of natural language data. (NLP)
The advantage of NLP is that doctors do not have to change their accustomed recording methods when writing cases and can express various information freely. They can have handwritten text or tape recordings. For recordings, the NLP system can use the speech recognition system to analyze sentences in natural language and process the medical information contained in them to enter data. The most basic function of NLP is to generate indexes for the terms used. These indexes can extract text containing one or more specified terms, and NLP will be able to connect them and process them to make inferences.
(3) Biosignal and medical image processing
With the introduction of a large number of digital instruments and equipment in hospitals and the application of LIS, PACS and other medical information systems, biosignals and medical images are processed through them Processing has gradually been digitized, and these digital medical information can be integrated into electronic medical records through the system's interface.
The transmission of information between different systems is through the system interface, and information standardization is the key to the interface. When two systems use the same standard, passing information is very simple.
If the two systems do not use the same standard, the interface must perform information conversion. The system that sends the information converts the data through the interface into a format that the system that receives the information can understand, or the receiving system converts the data through the interface into a format that can be understood by the system that receives the information. format. The standardization of information is a gradual process. In order to facilitate the interface between systems that use non-standard information, people have developed interface engines, which are used to convert non-standardized information into standardized information.
(4) Signature and modification of electronic medical records
Medical records are documents with legal effect, and medical record data serves as legal evidence. The security of medical data in medical records is extremely important, not only to safeguard the interests of patients but also of medical personnel. Every time the electronic medical record is written, it must be signed before it can take effect. If you reopen the electronic medical record to make changes, the EPR system will perform different processing for different changers. For example, when a superior doctor deletes or adds content to the medical record, the system automatically turns the deleted content red and adds a text in the middle. A horizontal line; if the chief physician deletes or adds content to the medical record, the system will automatically turn the deleted content red and add two horizontal lines in the middle of the text, and the newly added content will turn red and add two horizontal lines below the text. horizontal line.
[Edit this paragraph] Template format
(1) Paper size
(2) Page setup
(3) Layout requirements
(4) Medical record paper format
How to make the case
Brief description of electronic medical records
(1) Electronic medical records template Header, footer, production points
Use Word as the editor to create a medical record template. The medical record template should comply with the writing requirements for medical records in the fourth edition of "Routine Medical and Nursing Technical Operations".
①The common format of the header is "name, department, bed number, medical record number". Some hospitals also include "medical record continuation pages", "medical record paper", etc., but there are currently no unified regulations. In order to prevent the header content from moving back and forth when actually inputting content, a table must be created in the header, in which the name, department, bed number, and medical record number are framed, leaving corresponding spaces for the doctor to enter when writing the medical record. Just fill in the patient's name and other information. Be careful to leave enough space to avoid misaligned lines.
②For table setting, use the table provided by Word to automatically apply unblocked format, so that the table structure will not be displayed when printed, making the medical record beautiful and elegant. When designing medical records, there is an input row at the bottom of the form that cannot be deleted, so that there is an appropriate space between the header and the content of the medical record.
③The footer should include the name of the hospital and the page number, and should generally be designed according to the requirements stipulated by each hospital.
(2) Key points in electronic case template content design
①The template content in the admission record should include "general items, chief complaint, history of current illness", etc. The case begins with "Admission Record", and a table is made below it. The first six items are in one column, and a column is left corresponding to them. The middle table is designed with four columns and six rows. Use the table provided by Word to automatically apply unblocked format, and adjust the appropriate column width so that there is enough space to enter the project content. In this way, the production items are arranged neatly and the input content will not be misplaced.
② List the chief complaint, history of current illness, personal history, family history, physical examination and other items together, and then outline the entire sequence of case writing in the case template.
[Edit this paragraph] Precautions for use
(1) The initial setting of system data must be done
(2) Strict security management
(3) Strictly organize data switching
(4) Ensure mutual organizational coordination
(5) Strengthen confidentiality and safety education for medical staff
(6) Strict medical order checking system
(7) Electronic case template specifications
(8) Strengthen management and monitoring