Electronic Medical Record (EMR) software is medical-specific software. The hospital electronically records patient information through electronic medical records. It includes: homepage, disease course records, examination results, doctor's orders, surgical records, nursing records, etc. etc., including 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.
1. Main functions
☆What you see is what you get interface style, intuitive and simple, easy to learn and use.
☆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, inserting elements into the table, table width manual or Automatic adjustment.
☆Supports data element binding and implements multi-document synchronous 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 legality check.
☆Supports required fields check.
☆Supports various medical-specific expressions (such as formula expressions for menstrual history, fetal heart rate, and dental caries location).
☆A rich medical picture library and a powerful medical vector diagram editor that supports multiple graphic editing, combination, split, Undo/Redo, complex filling, custom line type, copy, paste and other complex operations.
☆Supports the third-level inspection (third-level review) function of medical record documents.
☆Introduce a timeliness control mechanism and adopt a workflow-driven mode to automatically prompt tasks and promptly remind and urge medical staff to complete medical record writing work on time, quality, and quantity, effectively avoiding missing, omitted, and delayed writing of medical record documents. .
☆Introduce a messaging mechanism to monitor the entire medical record writing process in real time.
☆Support structured retrieval of electronic medical records.
☆Supports extraction, storage and retrieval of typical medical records.
☆Supports automatic scoring and evaluation of medical record quality.
☆Quick copy function.
☆Supports attaching various multimedia files (such as sound, images, videos, animations, etc.) to documents as attachments.
☆Medical record documents can be exported in XML format to facilitate data exchange.
☆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.
2. Purpose
1. Save a lot of time for medical staff
For doctors, they have to treat multiple patients every day, and 70% of their daily work time is spent 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 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.
2. Improve the quality 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 unclear. Transcription is prone to potential errors. It can only be passively used as a reference for doctors to make decisions, and cannot provide active reminders, warnings or suggestions. The phenomenon of erasure is prominent, and the writing of medical history is highly arbitrary. By providing complete, authoritative, standardized and rigorous medical record templates, the electronic medical record system avoids common problems such as illegible writing, missing pages, missing items, vague and non-standard terms, etc., improves the medical record review pass rate, and improves the hospital's overall competitiveness.
3. Provide first-hand valuable information
In terms of medical statistics and scientific research, it is difficult to screen typical cases and search statistics. The electronic medical record system can not only quickly retrieve various required medical records, but also make the previously time-consuming and laborious medical statistics very simple and fast, providing first-hand information for scientific research and teaching.
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