Electronic Medical Record (EMR) is a medical special software. Hospitals electronically record patients' medical information through electronic medical records, including: home page, course records, examination results, doctor's orders, surgical records, nursing records, etc., including both structured information, unstructured free text and graphic and image information. It involves the collection, storage, transmission, quality control, statistics and utilization of patient information. As the main information source in medical treatment, it provides services beyond paper medical records to meet medical, legal and management needs.
[ Editing this paragraph] Purpose
1. Improving the qualified rate of Grade A medical records
On the one hand, improving the qualified rate of Grade A medical records needs to be guaranteed by various management means and rules and regulations; on the other hand, it needs to combine various new technologies, integrate various resources through feasible technical channels, clearly assign responsibilities to specific individuals, improve the hospital's ability to manage the quality of medical records, and control them in advance through statistics, analysis, early warning and three-level quality evaluation. Improve the first-class rate of medical records, so as to improve the comprehensive competitiveness of hospitals.
Second, save a lot of time for medical staff and better serve hospitals and patients
For doctors, they have to treat many patients every day, and 7% of their daily work is due to manual writing of medical records. Through various standardized templates and auxiliary tools provided by the electronic medical record system, medical staff can not only be freed from the tedious and repetitive writing of medical records and concentrate on the diagnosis and treatment of patients, but also the medical records written by templates are more complete and standardized. At the same time, doctors can spend more time improving their professional level and treating more patients, thus improving the economic benefits and medical level of hospitals.
Third, improve the quality of medical records
By providing a complete, authoritative, standardized and rigorous medical record template, the electronic medical record system can avoid common problems such as scribbling, missing pages, missing items, vague and irregular terms, improve the qualification rate of medical record review and improve the comprehensive competitiveness of hospitals.
Fourth, improve the ability to prove medical disputes
Medical records are legally effective medical records, which provide legal documentary evidence of medical behavior facts for medical accident identification and medical disputes. If there is a legal dispute, the unwritten content will be regarded as no inquiry or inspection, then the court will consider it a fault, which will cause great passivity and even losses to the hospital. Through the standardized medical records, problems such as semantic ambiguity, scribbling, missing pages and missing items are avoided, and possible avoidable errors that may have adverse effects on all aspects of the hospital are reduced, which provides a strong legal basis for inversion of evidence. It not only protects the legitimate rights and interests of hospitals and medical staff, but also brings benefits to the reputation and economic benefits of hospitals.
V. Stabilizing and expanding the source of the disease
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 improving patients' recognition of the hospital.
VI. Improving the standardization of medical records
The content of paper medical records is in the form of free text, and the handwriting may be unclear, the content may be incomplete and the meaning may be vague. Copying is prone to potential errors. It can only be passively used as a reference for doctors to make decisions, and can't realize active reminders, warnings or suggestions. The phenomenon of alteration is prominent, the writing of medical history is arbitrary, the computer-printed medical records are not copied properly, which leads to the phenomenon of "arrogant", the content of a medical record is missing, and the medical record is not completed in time. The electronic medical record system of Medical Record Collection has fundamentally solved the above problems.
VII. Scientific research, teaching and statistical analysis provide first-hand valuable information
In medical statistics and scientific research, typical medical records are difficult to screen, and it is difficult to retrieve statistics. Electronic medical record system can not only quickly retrieve all kinds of medical records needed, but also make the previous laborious medical statistics 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 hospital development in China and make Chinese medicine integrate with world science and technology as soon as possible, Dalian Huiyuan Electronic System Engineering Co., Ltd. has concentrated a lot of manpower and material resources, learned from the advanced experience of HIS at home and abroad, and developed the hospital management information system in combination with the traditional management mode and actual needs of domestic hospitals. In 21, Huiyuan Hospital Management Information System was recognized as a software product by Dalian Information Industry Bureau. This product is a hospital management information system that is truly suitable for China's national conditions, and it is the only hospital information system with independent intellectual property rights that can compete 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 the structured storage of medical records and is a real structured electronic medical record system.
☆ Support rich medical record template libraries (simple element library, complex element library, small template library, large template library and common language library).
☆ The medical record template distinguishes male and female patients.
☆ Provide medical input methods and medical phrases.
☆ Support continuous printing (continuous typing), repeated printing and printing by page number of course records and nursing records.
☆ Strong table processing ability (making table medical records conveniently), supporting table nesting, merging cells, splitting cells, deleting rows, deleting columns, adding rows, adding columns, inserting elements in tables, and manually or automatically adjusting table width.
☆ Support data element binding, and realize multi-document synchronous refresh technology.
☆ Key words are supported and cannot be deleted. (such as "chief complaint, current medical history, past history, family history, general examination, specialist examination" and other key words).
☆ support the validity check of input values.
☆ required item checking is supported.
☆ Support various medical special expressions (such as the formula expression of menstrual history, fetal heart rate and dental caries position).
☆ Rich medical picture library and powerful medical loss graph editor support complicated operations such as editing, combining, splitting, Undo/Redo, complex filling, custom line type, copying and pasting.
☆ Support the three-level examination (three-level audit) function of medical records.
☆ Support the reservation of modification marks, and keep the modification marks of doctors at all levels.
☆ data locking, check-in and check-out mechanisms are supported.
☆ Introduce the aging control mechanism, adopt the workflow-driven mode, automatically prompt the tasks, remind and urge the medical staff in time, and complete the medical record writing on time, in quality and quantity, effectively avoiding missing, missing and delayed writing of medical record documents.
☆ The message mechanism is introduced to monitor the whole process of medical record writing in real time.
☆ Support structured retrieval of electronic medical records.
☆ Support offline writing of medical records.
☆ Support the extraction, storage and retrieval of typical medical records.
☆ Support automatic scoring and evaluation of medical record quality.
☆ Support online borrowing and approval of medical records.
☆ quick copy function.
☆ It supports attaching various multimedia files (such as sound, image, video, animation, etc.) as attachments to documents.
☆ Medical records can be exported in XML format, which is convenient for data exchange.
☆ support wireless handheld devices such as PDA.
☆ support seamless access of HIS, PACS, LIS, RIS and other systems.
☆ provide operation safety, data transmission safety and data storage safety.
☆ Medical records are compressed and encrypted, which greatly saves storage space.
☆ Support the entry and printing of three measurement sheets.
[ Edit this paragraph] Features
(1) Standardize case writing, improve case quality and realize case standardization.
(2) High transmission speed.
(3) Good enjoyment of * * *.
(4) large storage capacity.
(5) Easy to use.
(6) low cost.
[ edit this paragraph] components and classification
components: (1) basic information
(2) diagnosis and treatment information
classification: (1) general information of patients
(2) symptom information
(3) sign information
(4) laboratory examination information
.
① Basic conditions of structured data input
A large amount of information in cases can be directly input by medical staff, and the basic conditions of structured data input are structured system model, knowledge-driven content, predefined vocabulary and synthetic expression rules.
② structured data entry method
(2) natural language data entry. (NLP)
The advantage of NLP is that doctors can freely express all kinds of information without changing their customary recording methods when writing cases. They can record with handwritten text or tape. For recording, NLP system can use speech recognition system to analyze sentences in natural language and process medical information contained in them, so as to input data. The most basic function of NLP is to generate indexes for the terms used. These indexes can extract texts containing one or more specified terms, and NLP will be able to relate them and make inferences.
(3) Biological signals and medical image processing
With the introduction of a large number of digital instruments and equipment in hospitals and the application of medical information systems such as LIS and PACS, biological signals and medical images have been gradually digitized through their processing, and these digitized medical information can be integrated into electronic medical records through the interface of the system.
information transmission between different systems is through the interface of the system, and information standardization is the key of the interface. When two systems use the same standard, it is very simple to transmit information. If the two systems are not using the same standard, the interface must convert the information, and the system sending the information will convert the data into a format that can be understood by the system receiving the information through the interface, or the receiving system will convert the data into an understandable format through the interface. The standardization of information is a gradual process. In order to facilitate the interface between systems using nonstandard information, people have developed an interface engine, which converts nonstandard information into standardized information.
(4) Signature and modification of electronic medical record
Medical record is a document with legal effect, and medical record data has the function of legal evidence. The security of medical data in medical records is extremely important, which not only protects the interests of patients, but also protects the interests of medical personnel. Every time you write an electronic medical record, you have to sign it before it can take effect. If you reopen the electronic medical record to make changes, the EPR system will deal with different changes for different people. When a doctor at the next higher level deletes or adds content to the medical record, the system will automatically turn the deleted content red and add a horizontal line in the middle of the text. 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 turn the newly added content red and add two horizontal lines below the text.
[ Edit this paragraph] Template format
(1) Paper size
(2) Page setting
(3) Layout requirements
(4) Medical record paper style
How to make an example
Briefly describe the electronic disease
(1) Header, footer and key points of making in the electronic case template.
① the common format of header is "name, subject, bed number and medical record number". Some hospitals also include "medical record continuation page" and "medical record paper", and there is no unified regulation at present. In order not to stagger the contents of the header back and forth when actually inputting the contents, a table must be established in the header, in which the name, subject, bed number and medical record number are framed, leaving corresponding spaces, and the doctor can fill in the patient's name and other contents when writing the medical record. Pay attention to leave enough spaces to avoid wrong lines.
(2) Form settings should be automatically formatted with the form provided by Word, so that the printed form does not show the form structure, which makes the medical record beautiful and generous. When designing the medical record, there is an input line at the bottom of the table that cannot be deleted, so as to keep an appropriate space between the header and the medical record content.
③ The footer should include the hospital name and page number, and should be designed according to the requirements specified by each hospital.
(2) design points of electronic case template content
① The template content in the admission record should include "general items, chief complaints, current medical history" and so on. The case begins with "Admission Record", and a table is made below it. The first six items are one column, and a corresponding column is set aside. The middle table is designed with four columns and six rows. Automatically apply the grid-free format to the table provided by word, and adjust the appropriate column width to make the column width have enough space to enter the project content. In this way, the production items are arranged neatly, and the input content will not be wrong.
② List the chief complaint, current medical history, personal history, family history, physical examination and other items together, and then set the whole sequence of case writing in the case template.
[ Editing this paragraph] Precautions for use
(1) Initial setting of system data must be done well
(2) Strict safety management
(3) Strict organization of data switching
(4) Ensuring mutual organization and coordination
(5) Strengthening medical staff's confidentiality and safety education
(6) Strict system of checking doctor's orders.