Information of electronic medical record software are required to have six function (1)

EMR (Electronic Medical Record, EMR) is a special software for medical, hospital through electronic medical records electronically record patient information, it includes: Home, course records, inspection results, the doctor's advice, operation records, care records and so on, including both structured information, but also unstructured free text, graphics, images, information.

It involves the patient information collection, storage, transport, quality control, statistics, and utilization; In medicine as their primary source of information to provide services beyond paper medical records, meet the medical, legal and regulatory requirements. For electronic medical records numerous norms and requirements they need to pass the application software can be ground, electronic medical record software should integrate in the hospital information system, and to achieve the following six features.

Medical information collection capabilities

Electronic medical record software by hand or equipment acquisition (urgent) patient medical information, medical records and other information about electronic medical records.

Collection of information should be timely, complete, can satisfy the needs of clinical work, consistent with the Ministry of health, the basic standards for electronic medical records (for trial implementation) "in the" Chinese and medical terminology, requires accurate statements expressed, punctuation and correct idiomatic "requirements. To achieve these goals, the electronic medical record collection tool acquisition instrument medical records is not only to do the easy-to-use, should also have the flexibility to call medical terminology, active extract sensitive indicators, on the review of medical contents logically and edit 2D vector graphics functionality.

Flexible call medical terminology refers to medical records acquisition tools according to the current project name or the content of the timely provision of the corresponding terms used in medical terminology, making the acquisition of medical information standardized, structured.

Active extract sensitive indicators refers to the acquisition of tools from the collection of information in the search to the diagnosis of disease, treatment of diseases are closely related to some important description or sensitive indicators to guide the user to set rules for the description, or index.

Such as appendicitis "metastatic patients with lower abdominal pain," and "test results" colon inflatable, obstetric patients "oligohydramnios" and "head", the pots are known as patients of infection "cut" and "the drainage is open", and so on, these descriptions and indexes may not be available for the income to the "electronic medical record basic data set" or "clinical document base template", but for a disease, which is very important that only gets the description, or index to the conduct of clinical path management, business process management. Therefore records acquisition tool cannot be mechanically moved some general neglect of those very important personality requirements to avoid many of the "information, basic useless," and "offer is not important, important to provide a" phenomenon. For now, at least it should be the Ministry of health has published clinical path management disease sensitive indicators collected software for medical records acquisition tool called.

On the medical records for logic review refers to medical records acquisition tool can call set records audit rules, on the acquisition of information integrity review and logic review.

Major review of the medical information content is complete, the archived documents is the timely acquisition and archiving; Review of medical history of significant description and key indicators for logic errors, such as male patient medical records have no female physiology of description, not doing surgery patient medical records have no operation records, etc.

Editing 2D vector map refers to editing medical graphics, medical instruments sometimes need to insert some schematics, and in particular surgical, facial features, obstetrics course records and surgery is more rare in the record, these diagrams is a "graphical" instead of "picture", requiring medical records acquisition tool can call medical graphics libraries, figurative shape to edit records in the instrument after save the corresponding location.

Medical workflow management features

Medical information acquisition, subject to the constraints of medical workflow is required to conduct follow-up actions, such as practice staff writing course records, the need for the physician to review, and signature; Senior physician of the wards records also need to review and signature.

Consultation request, surgical applications to flow between the different sections, modify, check. Prescriptions issued after being audited, fees, prescription, dispensing and so on; Secondary checks after meted out to review and note the fee, execution, complete report card and so on. Clinical management of the full path is the sequence consisting of medical work processes, such as one day should be submitted to the medical documents, observing what clinical indicators, what long-term release, release which temporary orders, how health education, which exceptions should be found for how to deal with, and so on. These business activity flow is not fixed, you often need to adjust are added or removed. These business activities have started, send, requisition forms, sign and return, message notifications, such as links in the end, both serial and parallel process, workflow, its processing can occur automatically handles, manual handling, Leapfrog, jump and termination.

To meet these needs, the clinical work of electronic medical record software should use workflow technology to the medical workflow control and management, available in the software embedded workflow engine.

In this way, both timely and prompt medical staff also need to complete the work, which avoid negligent omission occurred; Can be easily administered medical service personnel to carry out real-time monitoring of control; Could greatly facilitate the maintenance management software. Fusion a workflow technology electronic medical record software to promote the protection of medical quality, improving health and safety.