Ministry of Health on the issuance of "electronic medical record

system function (for Trial Implementation)" notice 


  


  

  

 

Provinces, autonomous regions and municipalities health bureau, health bureau of Xinjiang Production and Construction Corps:


Deepening the reform in accordance with the relevant medical and health work, to standardize the management of electronic medical records medical institutions, medical institutions, specifically electronic medical records system should have the function of electronic medical records to better play to the support of the work in the medical role in promoting the core electronic medical records hospital information construction work, the Ministry formulated the "electronic medical record system function (for Trial Implementation)." Is issued to you, please comply.
 
December 30, 2010


 


 
 
 
 
 
 


Electronic medical records system functional specification (Trial)


 


Chapter I General Provisions


The first medical institution to regulate the electronic medical records management, electronic medical records system clearly medical institutions should have the function of electronic medical records to better play the work in the medical support role, to promote electronic medical records as the core hospital information construction work, according to " Republic of China on Medical Practitioners, "" medical institution regulations "," basic norms of medical records, "" basic norms of electronic medical records (Trial) "and" the basic structure of electronic medical records and data standards (Trial) "and other laws, regulations and norms documents, the development of this specification.

Article II of this Code apply to health care institutions to establish electronic medical records system, use, data preservation, sharing and management.

Article III refers to electronic medical records system to support electronic medical records medical information in-house collection, storage, access, and online help, and focusing on improving quality of care to protect the health safety and improve the efficiency of the provision of medical information processing and intelligence services of the computer information system , both applied to the door (emergency) clinics, wards, clinical information systems, including inspection and examination, pathology, imaging, ECG, ultrasound and other medical departments of the information system.

Article IV of this Code is to establish and improve medical institutions function of electronic medical records system evaluation criteria, focusing on improving the quality of care to protect the health safety and improve the efficiency of relevant important medical functions, does not involve technology to achieve the functions and methods.

Article is divided into electronic medical records system functions required, recommended and optional three grades. Function is necessary for electronic medical records system must have the function; recommendation feature is the electronic medical record system currently available can be temporarily, but in the next step should focus on the development of expanded functionality; optional feature is the further improvement of electronic medical records system, medical institutions, selected according to the actual situation of the functions.

 


Chapter II the basic function of electronic medical records system


Article VI of electronic medical records system should have user authorization and authentication, the use of audit, data storage and management, patient privacy and data management, and other basic functions dictionaries, data protection in electronic medical records security, reliability and availability. Electronic medical records data center management to establish the basis to achieve information in real time uploading and automatic backup to the hospital data centers and third party storage center, in the permissions set on the basis of certain data resource sharing, and protection of data security.

Article VII of the user authorization functions includes the following functional requirements:

(A) of the required functions:

1. Create user roles and working groups for each user assigned the function of the independent user name.

2. For the role, the Working Group and authorized users and assign appropriate permissions to cancel the user's function to provide the user canceled the retention of the user in the system for historical information.

3. To create, modify electronic medical records access rules, users automatically based on business rules function of the provisional authority, electronic medical records to meet the needs of flexible access authorization.

4. Permissions to modify the operation log provides a record function.

(B) of the recommended features:

1. On the user rights to be time-limited features, no longer than the time set the appropriate permissions.

2. Provided by law and regulations, the patients themselves and their guardians, agents authorized to access the part of the medical records functions.

Article VIII of the user authentication function includes the following functional requirements:

Essential functions:

1. Users of electronic medical records system must be standardized user authentication, support at least the user name / password, digital certificate, fingerprint recognition, a authentication method.

2. The system uses the user name / password authentication, the user must change the initial password, and provide strong authentication password validation rules to prevent users too simple.

3. Set the password is valid, the user can not use more than the validity period of password login system.

4. Set account lockout threshold time, the user multiple login errors, automatically locks the account, the administrator account has permission to lift the lock.

5. System uses the user name / password authentication, the administrator has permission to reset your password.

Article IX using the audit function includes the following functional requirements:

Essential functions:

1. User Login electronic medical record system, access electronic patient records, automatically generated, saved using the logs, and provide per-user tracking to see its all operations functions.

2. On the electronic medical record data, create, modify, or delete anything automatically, save audit logs (including at least operation time, the operator, the operation content, etc.), and provide audit tracking view at all of its operators, press operators track view all of its operations and other functions.

3. To provide the user logged in with the audit function of the digital certificate.

Article data storage and management features include the following functional requirements:

(A) of the required functions:

1. To support the conversion of various types of medical records, storage management, and use of open data storage format, use of non-specific system or software able to read electronic medical records.

2. Provides the standard format for storing data or stored data into a standard format of the function; no standard format for handling data, to provide data stored in proprietary formats will be converted to other open-format data.

3. In the data items stored in electronic medical records to retain the text record.

4. To provide long-term management of electronic medical record data and random access capabilities.

5. With electronic medical records data backup and restore functions; when the electronic medical record system update, upgrade, should ensure that the inheritance and use the original data.

6. Have the protection in electronic medical record system and data security measures, data backup mechanism.

(B) of the recommended features:

1. In an appropriate way to maintain complete medical records, be able to reproduce the original style of medical records.

2. When the time limit beyond the business rules or the scene, and then modify the prohibition of medical records.

3. Qualified medical institutions should establish an information systems disaster recovery system.

Article XI patient privacy protection requirements include the following features:

(A) of the required functions:

1. Set the security level of electronic medical records functionality, the operator of the rights of the different levels of management and users to have permission to access the appropriate level of electronic medical records confidential. Authorized users to access electronic medical records, the Auto Hide privilege level higher than the user rights of electronic medical records.

2. When the medical staff due to work not directly related to the patients need to view electronic medical records data, alerts the user to follow the requirement to use electronic patient medical records.

(B) of the recommended features:

Provide patients with electronic medical records were anonymous processing functions for the protection of the necessary health and other private patients.

 Article XII of the dictionary data management features include the following requirements:

Essential functions:

1. Provide all kinds of dictionary entries to add, delete, modify, and other maintenance functions.

2. To provide dictionary data version management features, the dictionary data update, upgrade, should ensure that the original inheritance and use the data dictionary.

 


Chapter III of the main functions of electronic medical records system


Section I create functional electronic medical record

Article XIII to create electronic medical records for patients, patients must be given a unique identification number, the establishment of the basic property information including patient master index of records to ensure that patients with a variety of electronic medical records related records accurate and unique identification number corresponding to the patients.

Article XIV of the main index to create electronic medical records functionality includes the following functional requirements:

Essential requirements:

1. For patients (including emergency or other circumstances of uncertainty as patients) to create a unified electronic medical record and given a unique identification number encoded function, through the identification number can be found in patients with electronic medical records information.

2. Electronic medical record for each patient to create a unique primary index, and recorded the patient information (should at least include the patient name, gender, date of birth, resident in address, etc.), and basic information for patients to make the necessary changes, to add and improved.

3. For the identification of patients with other types of distribution functions, such as medical record number, health insurance number, ID number, etc., and can identify various types of electronic medical records and unique identification number associated with it.

4. To provide unique identification number in accordance with patients, other types of identification, classification and other basic items of information retrieval, query function in patients with basic information.

5. Basic information on the patient major projects (such as name, gender, date of birth, etc.) be modified, provide change log records.

Searching in Article XV merge electronic medical records include the following functional requirements:

Essential functions:

Electronic medical records provide automatic re-check function can be the same in patients with multiple electronic medical record number that uniquely identifies the patient to correlate the unique identification number can be found through the patient's electronic medical record information.

 


Information Management Section functions in patients with previous treatment


Article XVI electronic medical records system should provide treatment in patients with previous information collection, management, storage and display functions, so that medical staff can fully grasp the situation in patients with previous treatment.

Article XVII past history of disease management include the following functional requirements:

(A) of the required functions:

1. Diagnosis of patients with past (or complain) and the treatment increased the content of such records, modify, and delete functions, documentation should include at least the disease (complaints) description, diagnosis, physician diagnosis, diagnosis date.

2. On the records of patients with previous surgery and other content to add, modify, and delete functions, documentation should at least include the operation name, date of surgery, surgeon, and more.

3. The patient medication history and other records of the past to add, modify, and delete functions, documentation should include at least the name of the drug, medication start and end time, dosage, route, frequency of second-class content.

4. Gathering information about the patients past the function of out-patient clinics, outpatient clinics, including treatment information should be at least the date, patient departments, diagnosis, and diagnosis of patients in accordance with the classification code entry.

5. To provide a free text-entry diagnosis (or complain), surgical and operating name of the function.

(B) of the recommended features:

The medical records from the patient to automatically extract diagnostic information, and classified to the Diagnosis of the history of the management functions.

Article XVIII of drug allergies and adverse reactions of the history of management features includes the following functional requirements:

Essential functions:

Patient history of drug allergy and adverse reaction history to add, delete, modify, and other operations functions, history of drug allergy documentation should at least include allergy medications, allergy symptoms, severity, dates, etc.; history of adverse drug reaction documentation should include at least adverse symptoms, causes, severity, time of occurrence and so on.

Article XIX electronic medical records system should be able to show the patients according to type a complete past medical history, drug allergies and adverse reaction history, outpatient and hospital care information.

 


Section III medical records management


Diershitiao medical records management functions for the medical, nursing and inspection test results and other medical electronic instruments to create, manage, store and display features such as support.

Article created a medical records function contains the following functional requirements:

(A) of the required functions:

1. In accordance with the Ministry of Health "basic norms of medical records" and "basic norms of electronic medical records (Trial)" requirements, create the components of medical records medical records functions, and automatically record creation time (year, month, day, hour, minute ), founder of the medical part of the name.

2. To provide information on medical records Supplement, to create, modify and other operating functions, the operator identification should be conducted, save previous operation prints, marking the exact operating time and operator information.

(B) of the recommended features:

1. To provide electronic medical records during hospitalization according to patient records, automatic generation of the medical record the number of days in the hospital, confirmed the date, discharge diagnosis, surgical and operation, cost information, nursing and other information functions.

2. To provide for clinical trial patients, teaching medical records of patients identified other special features.

Twenty-two medical records entry and editing features include the following requirements:

(A) of the required functions:

1. To support the various components of medical record entry and editing functions.

2. To provide in accordance with the medical part of the content and requirements, according to data in electronic medical records system to automatically generate part of the function of medical records.

3. To provide free text entry capabilities.

4. Provide the contents of medical records in the specified copy and paste the same information in patients with my medical records functions; prohibit copy, paste, I patient information non-functional.

5. To provide a structured interface templates, which could be part of medical records, disease disease to select the desired template; template content should be consistent with the disease, current treatment guidelines, regulatory requirements.

6. Provides customized medical records for the medical function of the default styles, default styles, including paper size, font size, layout and so on.

7. Providing temporary storage of patient medical records are not complete, and authorized users to view, edit, complete the medical records, patient medical records to provide confirmation of completion and record the completion time of the function.

8. To provide inpatient medical records dual signature feature, when the trainee, probationary period when the medical staff to write medical records, medical institutions should be registered by the physician review, modify, and retain the writers and reviewers of the dual signature.

9. To prevent the state is in the editing interface of medical records in another open editing.

(B) of the recommended features:

1. To provide in-patient medical records inserted into the patient basic information, prescription information, auxiliary inspection reports, vital signs and other related information content.

2. To provide medical records and two pieces of content templates support.

3. To provide a structured medical record project is reasonable checks and prompts, including project between the independent inspection and projects, projects and individual patient characteristics of the correlation between the check.

4. To provide medical records included to show the style of the entry editing and saving; to provide medical records entry WYSIWYG editing.

(C) Optional features:

1. To provide in-patient medical records in the embedded images, tables, multimedia, data and editing functions.

2. To provide in-patient medical records into the system from internal or external database of disease-related knowledge, knowledge of text features.

3. Provide a common thesaurus features auxiliary input, thesaurus, including the name of the symptoms, signs the name, disease name, drug name, operation name, operation name, the name of such care level.

4. To provide structured (interactive elements) template function of auxiliary input and retention of the structure of medical records form the template structure.

5. In the medical record entry is automatically saved in the editing process, editing content, and abnormal disruption in the system, restoring the function of the document being edited.

Twenty-three hospital medical records to modify features, including the following functional requirements:

(A) of the required functions:

1. To provide medical records to modify, and delete functions, and automatically recorded and stored in medical records of all traces of changes should include at least modify the content, change people, change time.

2. On the medical records in accordance with the user to modify the rights management feature that allows a higher level medical personnel changes created by the junior medical staff medical records.

(B) of the recommended features:

Provide medical records to modify and print settings prohibit function.

Twenty-four medical template management capabilities, includes the following functional requirements:

(A) of the required functions:

1. To provide user-defined chart templates, and create a template for rights management, user-created templates can be used with permission.

2. To provide a template for the use of medical records management functions to grade, use of medical records templates include: creating personal, department, hospital-wide.

(B) Optional features:

1. Provides structured templates to create the structure of the template contains at least one option, more options, required, fill in the blank, can not modify the text and other elements.

2. To provide a template defined in the function of automatic macro replacement elements, the macro can be used to replace elements that often appear in the medical records of patients name, gender, chief complaint and so on.

3. To provide a structured template, set the input element of the structural approach, range, validation rules and other property features.

Twenty-five nursing records management functionality includes the following functional requirements:

Essential functions:

1. To provide patient record vital signs, vital signs, including: temperature, pulse, respiration and blood pressure.

2. To provide custom functions vital signs of the project.

3. To provide surgical care records of a single entry function.

4. To provide critical care records of a single entry function.

 


Section prescription management


Twenty-six major medical advice of your doctor to issue management, delivery and execution management, the focus is to support patient and the door (emergency) appointment of the various types of medical advice to ensure the correctness of the implementation of medical advice and prescription records the key implementation point in time.

第二 seventeen general physician order entry functions for all types of medical advice (including the door (emergency) clinics all kinds of prescription and medical advice), contains the following functional requirements:

(A) of the required functions:

1. Physician order entry function should support the clinical and content of all types of medical order entry, medical advice should include at least the long-term prescription start date and time, the contents of long-term medical advice, stop date and time, temporary medical advice time, the contents of the temporary medical advice, physician signature, execution time, the implementation of nurse signatures.

2. Physician order entry and processing of all the obvious parts of the interface shows the function of patient information, patient information should include at least the unique patient identification number, name, gender, age and so on.

3. Provide physicians with prescribing the right level to match the prompts.

4. To provide medical order entry functions and template assisted physician order entry functions into groups, physicians can select the patient's condition, modify some or all of the doctor's advice, along with free text entry using the prescription of the function.

5. To provide Yizhu fill entry function, need for rescue Weijihuanzhe issued verbal instructions, and should be immediately after the rescue and truly make records in, and give special logo.

6. Physician order entry time and automatically records information about the function of physician input.

7. To provide medical advice dual-signature feature, when the internship, the probation period by certified medical personnel and medical staff training requirements issued by superior doctors prescription, it should be registered after the medical doctors reviewed, modified, effective upon confirmation and retain writers and reviewers of the double signature.

8. To provide medical advice and basic rationality of the content integrity check function.

9. To provide medicines, medical supplies, treatment and classification of items such as a dictionary search, code search, keyword search and other functions for the user to input your medicines.

10. To provide medical advice showed that patients function of past ill treatment.

(B) of the recommended features:

1. To provide input, processing of non-hospital drug treatment program functions in order to be issued to the patient prescription drugs purchased, or issued outside the hospital clinic application form.

2.'s Health insurance policy provides medical advice to automatically check compliance and hints.

3. To provide the corresponding prescription charges displayed price shows the amount of information in patients with prepaid payment functions.

(C) Optional features:

1. To provide a fixed time interval the input function of the long-term medical advice.

2. Provide early entry into force in the future of the medical advice of a function of time.

3. To provide a single operation to stop the current function of all the valid doctor's advice to facilitate the patient before surgery or before discharge to stop all medical advice.

第二 eighteen prescription drugs (with the door (emergency) clinic prescriptions) input function, in addition to satisfying the general physician order entry functions, includes the following functional requirements:

(A) of the required functions:

1. To provide drug treatment physician order entry functions, prescription drugs, at a minimum include the name, size, dose, route of administration, frequency of use, recording time, the executor, the implementation of beginning and ending time, the use of notes, antimicrobial skin test and so on.

2. In all physician order entry and processing interface shows whether the patient was part of a sign of drug allergy function.

3. To provide proactive tips commonly used drug dosage and description of the drug search function, and based on drug incompatibility, allergic reactions to prescription drugs and tips on automatic review; in accordance with the relevant provisions of rational drug use, when physicians choose drugs and super-normal dose of restrictive medication, the system alerts.

4. In accordance with the "prescription management," the request, door (emergency) to review patient prescriptions and hints.

5. To provide pharmaceutical grade antibiotics and other special-use management features.

6. To provide the identity of self-medication function.

7. Providing a single prescription, prescription printing, and output.

(B) of the recommended features:

1. To provide a list of features commonly used drugs, including specialist commonly used drugs, a list of commonly used drugs such as disease, and prompt drug prices, inventory and other related information.

2. To provide prescription medication from the patient's previous copy, import, modify and create a new prescription after the function.

3. To provide in accordance with the relevant provisions of rational drug use on medical advice, prescription audit function, including the reasonableness of drug testing, drug and medical insurance policies on the new rural cooperative compliance inspection.

4. Furnishing drugs generic name, trade name, the role of pharmaceutical drugs keyword search functional classification.

5. To provide hospital patients discharged with a prescription drug print.

(C) Optional features:

1. To provide according to patient age, weight, liver and kidney function and other personal circumstances of the function of calculating the amount of drug use.

2. To provide prescription drugs, non-prescription drugs hints.

3. To provide in accordance with the "National Essential Drugs List", "National Formulary" on the prescription, prescription review and hints.

4. Provision of the new rural cooperative medical insurance and drug policy query functions, including drug list, drug directories specific diseases, the special provisions of drug use, dosage requirements, at their own expense ratio of inquiries.

Twenty-ninth class of physician order entry of inspection testing and processing functions, in addition to satisfying the general physician order entry functions, includes the following functional requirements:

(A) of the required functions:

1. To provide physician order entry for inspection and examination functions, the input content should include at least check the site or specimen type, inspection items, specimen conditions and so on.

2. To provide various types of inspection and examination application form template, project dictionary and other functions, including checking the dictionary project items, drawing materials, parts and specimens dictionary.

3. Provision for inspection and examination application form generated automatically when access to patient information and clinical diagnosis and treatment of basic information functions, and content integrity of the application form, rationality review, tips.

4. To provide for the designated doctor's advice for inspection and examination identified the function of the degree of urgency.

5. To provide various types of inspection and examination application form printing function.

(B) of the recommended features:

1. Doctor's orders to provide structural inspection and examination functions in a structured way to check the site entry, inspection items and so on.

2. To provide query execution state of an application for inspection and examination functions.

3. To provide for the inspection and examination application clinical diagnosis associated with the audit function.

4. To provide information on the project knowledge of inspection and examination functions, including checking the conditions, considerations and so on.

The third ten doctor's advice to deal with executive function includes the following functional requirements:

(A) of the required functions:

1. To provide medical advice to modify, submit, review, implementation, back, print prescription functions.

2. When the physician ordered a new, stop, cancel the doctor's advice, the provision of new open, stop, cancel the doctor's orders and manual verification of the list of confirmed features, and through on-screen or voice prompts, etc. inform the nurses dealt with accordingly.

3. When the doctors to cancel doctor's orders, the system automatically in accordance with the clinical diagnostic and treatment practices for review and record the doctor's orders to cancel the time and operating physician information.

4. To provide the content generated according to clinical need your doctor orders a variety of executive functions, and provide samples for inspection and examination of patients to print bar codes or bar codes associated with the function of patient specimens.

5. To provide medical advice in the implementation process, patient identification, medical advice, execution time, drug or specimen containers and the results suggest that functional verification, and support for bar code reading means and other computer applications.

6. To provide the type under doctor's orders, the current implementation, doctors, nurses and other inquiries and the implementation of the list shows the function of patients with doctor's orders.

7. To provide medical advice execution results (such as allergy test results, test sample collection time), the entry to the function of physician feedback.

8. To provide prescription monitoring the implementation and support query execution time doctor's advice, executors, check the time, reconciliation of people and other information.

9. To provide printing, selective printing, re-printed prescription orders, your doctor perform a single function.

(B) of the recommended features:

1. To provide on-demand implementation of a single combination of prescription generation functions, according to clinical practice, and based on prescription type, doctor's advice content, drug dosage forms, routes of administration and other types of doctor's orders the implementation of the portfolio generated a single.

2. To provide time for the implementation of bedside medical advice, executor of the automatic recording function.

(C) Optional features:

1. To provide input on the physician's prescription in advance the date to remind the nurses in the implementation of processing functions.

2. To provide medical advice and re-export, print function.

第三十一条 prescription template management features include the following functional requirements:

(A) of the required functions:

1. To provide medical advice template to create, modify, delete, and real-time synchronization with the function of a dictionary.

2. To provide medical advice category management templates, prescription templates can be set to a common template, templates and personal templates departments, and set the appropriate administrative privileges.

(B) Optional features:

1. To provide medical advice based on past prescription templates to generate a new content integration feature.

2. To provide the function of building structure templates, enabling users to customize the structure of the clinic project application form.

 

Check the inspection report management function V

Thirty-second report of inspection test management for all types of inspection, inspection reports collection, modification, inform and inspection report to show such support.

Thirty-third report of inspection test editing features include the following requirements:

(A) of the required functions:

Allow the inspection and examination reports of the completed sections to modify the function, and take the initiative to receive the report prompts the user for inspection and examination report has been modified to function.

(B) of the recommended features:

Modify the contents of the report provided, modified, modify the information of people and other records.

Thirty-fourth report of inspection test requirements of this function includes the following features:

Essential functions:

1. Or when users log in using the system, the system prompts the user take the initiative to have a new inspection and examination of patients report generation function.

2. Take the initiative to check the user is prompted for patients with abnormal test results and report the results of critical functions, and the critical value of the prompt.

Thirty-fifth report of inspection tests show features include the following functional requirements:

(A) of the required functions:

1. To provide inspection reports show the function of inspection, inspection report shall include at least the name of test items, results, sample collection time, inspection time, the operator, who reviewed the report, the audit time.

2. By the side of the inspection report interpretation of test results, check inspection reports at the show, clearly suggesting that the report is a preliminary report or confirm the report function.

3. Display check inspection reports, the system should be based on sex, age, menstrual cycles and other factors also check the test results showed normal reference range.

4. To provide inspection and examination reports related images or video display function, image or video processing and provide basic measurement browsing.

5. To provide inspection test results, output, printing function.

(B) of the recommended features:

Tips to take the initiative to provide patients with abnormal results check the function of inspection reports.

Check the thirty-sixth articles of hospital management inspection reports contain the following functional requirements:

Recommended features:

1. To provide inspection reports collected outside the hospital checking function, can check the report of the outer electron into the system, or outside the hospital imputation scanned paper inspection reports to the unified management of the system and displayed.

2. The provision of external hospital inspection identified the source of inspection reports, and the contents of the report are classified indexing functions.

 


Section VI show the function of electronic medical records


第三 seventeen medical records show the features are intuitive, effective and convenient way to show the medical records of patients, the medical staff fully and effectively control the medical records of patients to provide support.

第三 eighteen collation of medical records functionality includes the following functional requirements:

Essential functions:

Treatment provided in accordance with the chronological order, classify types of medical records of patients medical records.

第三 nineteen medical records of the search function includes the following functional requirements:

Essential functions:

Provide classification retrieval, access to medical records functions. Search projects should include at least the basic information of patients, visiting time, visiting departments, admissions, MD, disease coding information.

The fourth ten browsing of electronic medical records, including the following functional requirements:

(A) of the required functions:

Provide patients with all types of electronic medical records available on the content of independent software.

(B) of the recommended features:

WEB-based electronic medical records the way browser software.

第四十一条 electronic medical records show features include the following functional requirements:

(A) of the required functions:

1. To provide access to medical records and demonstrate the function of previous treatment, including the door (emergency) clinic, hospital, medical and other different data types.

2. To provide medical records at all and deal with the basic information screen shows the function of patient, patient information should include at least basic patient name, gender, age (date of birth), the patient unique identification number, patient number (hospital number) and case numbers.

3. To provide the patient's vital signs observations to show the trend in the form of function.

(B) of the recommended features:

1. To provide the test results will be checked in patients with previous numerical indicators to show the trend in the form of function.

2. Provides text-based inspection and examination results, historical results show the function of the control.

(C) Optional features:

1. Provide the same time show a number of physiological changes in trend function.

2. To provide medical record data also show signs of relevant information to modify the function, including at least modified, modify the person, modify the content of such information.

第四 twelve EMR Print / output capability includes the following functional requirements:

(A) of the required functions:

1. To provide medical records in electronic medical records of all kinds of paper printing, print format, the administrative department of the paper meet the health requirements of medical records.

2. To provide electronic medical records in accordance with the final content (without change marks) printing function.

3. To provide electronic medical records to print preview, follow the print function.

(B) of the recommended features:

1. To provide a doctor's medical records will be all or part of the batch printing function.

2. To provide the print specified in the medical records electronic medical records functions.

(C) Optional features:

1. To provide electronic medical records on the style of the print layout or export functions.

2. To provide various types of electronic medical records, medical records in electronic file format export function.

 


Clinical Knowledge VII function


第四 Clinical Knowledge Base features thirteen issued prescription for physicians, clinics and programs provide ancillary support selection. Application of clinical knowledge base focused on supporting the implementation of correct treatment measures for physicians to provide proactive tips and warnings, standard treatment behavior.

第四 fourteen Knowledge of clinical path management function includes the following functional requirements:

(A) of the required functions:

1. To provide artificial conditions according to the patient to determine the path into the clinical management of specific disease features.

2. To provide physicians based on clinical paths and options to generate various types of orders, and check the function of a single test application.

3. To provide the implementation of clinical pathways, variation and reasons for records.

4. To provide the definition of clinical pathways, the revised function.

5. To provide for the implementation of clinical pathway analysis, statistical functions.

(B) Optional features:

Provided under the patient's condition and prompt patients automatically determine whether conditions in clinical path management capabilities.

第四 fifteen features of clinical diagnosis and treatment guidelines include the following functional requirements Knowledge Base:

(A) of the required functions:

Provide access to, amend the functions of clinical diagnosis and treatment guidelines.

(B) Optional features:

Provide guidance to physicians based on clinical diagnosis and treatment guidelines, nurses in disease diagnosis and treatment, care and health guidance function.

第四 sixteen clinical database function includes the following functional requirements:

(A) of the recommended features:

1. Provides a typical case of the past, the external scientific literature stored in the database, and ready access to the function.

2. To provide the database under the key words to search features.

(B) Optional features:

1. Provides links to external database functions.

2. To provide updates on the database upgrade function.

第四 seventeen function rational use of medicines includes the following functional requirements Knowledge Base:

(A) of the required functions:

1. To provide patients with history of drug allergy according to doctor's orders or prescriptions for review and prompt warning function.

2. To provide patients with medication, the review function of the interaction, the scope of the review should include the newly opened and newly opened between drugs and the current drug of drug interactions.

3. Provide medical advice or prescription dose, route of administration 合理 of the undertaking of the function, the dose Heli Xing Yao consider the patient weight, age, Geti factors.

4. Provide medical advice or prescription of drugs and diseases in patients with contraindications between the review function.

5. To provide drug side effects, contraindications prompts on the need to monitor side effects, suggesting that the required inspection and examination items, and according to the patient pregnant, breastfeeding contraindicated the drug review function.

6. To provide a review of the function of repeated drug use, repeated drug use, including drug name, pharmaceutical ingredients and drug class duplication.

(B) of the recommended features:

1. To provide as input a new history of drug allergy in patients when the drug re-examine the current function.