What Is an Electronic Medical Records System?
Electronic medical record system is medical special software. Hospitals use electronic medical records to electronically record information about patient visits, including: homepage, medical records, test results, doctor's orders, surgical records, nursing records, etc., which contains both structured information and unstructured free text. There is also graphic image information. It involves the collection, storage, transmission, quality control, statistics and utilization of patient information.
Electronic Medical Record System
- Electronic medical record system, dedicated to medicine
- First, improve the qualification rate of medical records
- On the one hand, it needs to be ensured through various management methods and rules and regulations; on the other hand, it needs to integrate various new technologies and integrate various resources through feasible technical channels, clearly implement duties to specific individuals, and improve the hospital's quality management of medical records Ability to effectively remind and urge medical staff to complete the writing of medical records on time and quality through pre-control methods such as statistics, analysis, early warning, and three-level quality assessment. Increasing the Grade A rate of medical records, thereby improving the overall competitiveness of hospitals.
- Save time
- For doctors, multiple patients are treated every day, and 70% of the daily work is used to write medical records by hand. A variety of standardized templates and
- Chapter I General Provisions
- The first is to standardize the management of electronic medical records of medical institutions, clarify the functions that electronic medical records systems of medical institutions should have, better play the supporting role of electronic medical records in medical work, and promote the construction of hospital informatization with electronic medical records as the core. Laws, Regulations of the People's Republic of China on Practitioners, Management Regulations of Medical Institutions, Basic Specifications for Writing Medical Records, Basic Specifications for Electronic Medical Records (Trial) and Basic Framework and Data Standards for Electronic Medical Records (Trial) Normative documents, formulate this specification.
- Article 2 This specification applies to the establishment, use, data storage, sharing, and management of electronic medical record systems in medical institutions.
- Article 3 The electronic medical record system refers to computer information in medical institutions that support the collection, storage, access, and online help of electronic medical record information, and provide information processing and intelligent service functions around improving medical quality, ensuring medical safety, and improving medical efficiency. The system includes both clinical information systems used in outpatient (emergency) and ward, as well as information systems in medical technology departments such as inspection, pathology, imaging, ECG, and ultrasound.
- Article 4 This specification is a functional evaluation standard for medical institutions to establish and improve electronic medical record systems. It focuses on important functions related to improving medical quality, ensuring medical safety, and improving medical efficiency, and does not involve technologies and methods for implementing various functions.
- Article 5 The functions of the electronic medical record system are divided into three levels of required, recommended and optional. Mandatory functions refer to the functions that the electronic medical record system must have; recommended functions refer to the functions that the electronic medical record system currently does not have, but should be expanded in the next step of development; optional functions refer to medical institutions to further improve the electronic medical record system Select the function to be implemented according to the actual situation. [1]
- (1) The initial setting of system data must be done well
- (2) Strict safety management
- (3) Tightly organize data switching
- (4) Ensuring mutual organization and coordination
- (5) Strengthening confidentiality and safety education for medical staff
- (6) Strict doctor order checking system
- (7) Specification of electronic case template
- (8) Strengthen management and monitoring