Chengzhi electronic medical record management system

With the further expansion of hospital management informatization, the "electronization" of medical records is an inevitable trend for hospitals to move towards scientific, standardized, information-based and modern management.

Chengzhi Electronic Medical Record Information System (CZEMR) is based on the requirements of the Ministry of Health's "Medical Record Writing Standards" and closely combines the characteristics of my country's medical record writing, adopting a new model of structured and free entry, allowing free writing and easy entry.

In order to meet the needs of hospitals of different sizes, Chengzhi Electronic Medical Records (CZEMR) is divided into three categories: CZEMR-Type I, Type II, and Type III, which are suitable for first-, second-, and third-level hospitals respectively.

Chengzhi Electronic Medical Record Information System (CZEMR) has a powerful interface function and can interface with hospital HISLISPACS and other software, so that all hospital data can be fully shared.

Function introduction:

1. Patient management: used for adding, deleting, and modifying basic patient information. The operator can automatically extract patient information from the hospital charging software (HIS) through the patient's name, hospitalization number, and admission date, or extract the patient's existing information through past medical records. Supports the automatic extraction of participating physician information during patient registration, making it easier for operators to review medical record information in real time and reducing human errors in the medical record writing process.

2. Template management: There are two parts: custom templates and inherent templates, which are mainly used for adding and editing commonly used templates in the system. According to the different modules used by users, they are divided into large category templates, small category templates and system templates. Major categories of templates mainly include medical record homepage, admission records, disease course records, auxiliary examinations, nursing records, hospital infection records, etc. According to different usage rights, they are divided into personal templates, department templates, hospital-wide templates, etc., to achieve different departments with different permissions. Flexible use by users. The sub-category templates mainly include chief complaint, current history, past history, marriage and childbearing history, etc. Users can also combine existing templates according to actual needs to form custom templates. The system template is the core template of the system. Any template can derive a new template from the system template, making it easier to expand the template.

3. Outpatient and emergency workstation: Templates can be called to complete the writing of outpatient medical records, and commonly used medical terms in various professions are formed into a special thesaurus, which medical staff can select conveniently and quickly to improve the writing speed of outpatient medical records. Can issue prescriptions and apply for tests and inspections, and view relevant results.

4. Inpatient medical records: After the patient is admitted to the hospital, various records are provided with templates according to the system, which can be written conveniently and easily. All operations including admission records, disease course records, examination records, operation records, discharge records, various notifications, and medical record home pages are completed on the same interface. It can be created, edited, and printed in one stop, or it can be completed according to different business processes. , users can customize a variety of flexible modes.

5. Nursing records: The temperature sheet data is entered through a graphical interface, which automatically generates curves based on the corresponding data and supports WYSIWYG printing.

6. Quality control system: Body temperature monitoring. When the body temperature exceeds the set temperature, it will automatically prompt. Writing prompts and time monitoring, monitor and prompt various records of writing completed within the specified time. Medical record quality control, comment on the completion level of a medical record and give the medical record a score. Doctors with general authority of the archived medical record can no longer view the content of the medical record.

Features and advantages:

◆Follow the Ministry of Health's "Basic Standards for Writing Medical Records" to achieve standardization of medical records. Classification provides standardized templates for each subject to achieve expandable, structured, and framed entry.

◆Supports automatic calling of templates. The system will automatically call templates for different diseases in the department according to the department to which the user belongs, greatly reducing repeated entry operations.

◆Electronic medical records are stored centrally in a large database, using high-speed network transmission to retrieve and analyze medical records and related classification information by name, disease type and other keywords.

◆Adopt the form of electronic records, completely changing the complicated collection, sorting, cataloging and other aspects of management in the past. Replacing the original form of paper with recording media such as optical disks and magnetic disks can save costs and reduce waste, and can be stored for a long time.

◆Shorten patient consultation time and reduce unnecessary examinations. All departments share information and use external network interconnection to realize hospital-level data exchange, avoid repeated examinations, and improve the quality of diagnosis and treatment.

◆Support the authority management of medical record writing and modification by doctors at all levels. The electronic trace operation is implemented according to the doctor's level. After a high-level doctor changes the content of the medical record, the system automatically records the trace, with clear responsibilities and rights.

◆The medical record editing interface imitates Word, supports keyword knowledge base calling, supports font settings, picture and table insertion, various column and layout settings, and supports WYSIWYG printing.

◆At the same time, it provides functions such as medical record query, quality control, local saving of documents, local import of documents, classified and segmented printing, and offline document editing.