Paperless storage of the specific practices of 251 hospitals starting from September 2007, using virtual printer technology, the use of existing doctors, nurses and other business systems, workstations, printing, printing through the virtual interface information for each patient's medical record transferred from the hospital HIS system out to PDF format by long-term online archiving medical record number, centralized storage in the archive database of electronic medical records to facilitate access to comprehensive patient information on individual patients, through authorized security key to open the print service patients medical record.
Discharged only to keep medical records, hand-bound patients signed informed consent part of the paper medical record, including the duration of the remaining records, medical advice, examination and testing orders, single-treatment operation such as the contents of electronic medical records do not print directly stored in the hospital HIS system database to prepare for clinical inspection, copying patients, health insurance counseling to use.
251 hospitals and application of electronic medical record archiving system has the following 5 features:
1. Online records of the automatic archiving
Electronic medical records of all online content, the system will automatically trigger the archiving operation, there will be no archiving of electronic medical records into a standard PDF format and sent to the archive server.
2. Archive scanning paper medical records
The paper does not implement electronic medical records (mainly equipment certificate and number, etc.), electronic scanning means, automatically converted into a standard PDF format and stored in medical records archive server.
3. Archiving of electronic medical record audit
Audit function to provide archiving of medical records, electronic medical records must be archived and ward clerks department and director of audit, the final examination by the medical record room personnel, archive.
4. Archive search index
Provide a complete directory, the directory lists all of the electronic patient medical records stored in the main title of the document content, specifying the electronic filing or paper filing, and archiving of paper types, number, order and related content.
Electronic medical record by browsing archive documents, assist in the examination, modification or afresh in Section Suo index corresponding to the contents, the index of the updates require authorization, staff members may submit applications for the index changes, Yi Wei Hu index to help correct.
Use under various conditions to help quickly navigate to the needs of the patient electronic medical records, retrieval conditions include: patient ID, patient name, hospital number, patient date of birth, hospital departments, hospital stay, hospital departments, hospital time, attending physician, hospital diagnosis, surgical procedure, application supplies, treatment, operation names, and other important content.
5. By authority of print management classification
Archiving of electronic medical records to provide a print function to print electronic medical records is strictly controlled, in addition to authorization in the system has print permissions, it also must verify that the hardware key to print operation can be achieved. Browse personnel records in order to prevent copying by means of screen printing of electronic medical records, electronic medical records are provided with a view of the watermark, only a print privileges and who have both the hardware key can only print out the electronic medical records without the watermark.
Complete record of the electronic medical record system, print log, print to remind the operator is the first time or many times to print. Electronic medical records system also records the content and the number of print, recorded in paper medical records of a receiver, and scan the ID stored in the archive server.
For the traditional historical paper records, 251 hospital use, microform digital processing technology to achieve a complete paperless medical records. As the 251 hospitals in 2007 to achieve a paperless electronic medical record archiving and storage, no longer produce new paper records, with a one-time deal with the conditions of historical paper records.
251 hospitals with the most advanced of a machine-head technology, while generating microfilm records to produce digital images. This will not only ensure the legitimacy of historical records, but also to meet clinical medicine, teaching, research quick and easy access to use historical records. Microfilm only by a small amount of space occupied, and the traditional paper medical records take up a lot of space and maintenance costs compared to a year savings for the hospitals is considerable.
Paperless storage remarkable results
1. Save the human, financial, and material costs
251 patients discharged from hospitals each year about 4 million people, such as paper storage requires a lot of paper medical records need to purchase the aircraft and increasing medical records storage room. From the full implementation of electronic medical records storage, the part of each paper medical records an average reduction of about 30 sheets A4 paper, 90 by discharge / day per day for hospital medical records of only one can save paper and nearly 3000. From 2007, the implementation of paperless electronic medical records storage, more than two years our hospital has saved more than 1 million yuan print consumption. Because a lot of space occupied by Medical Records Storage and maintenance costs are substantial, the direct annual cost savings of up to 150 million yuan.
2. Optimize the case management functions
In the past, medical record room staff mainly engaged in paper-based medical record for finishing, binding, shelving and other complicated work, part of the medical records in question may be in the hands of more than 5 times can be filed. At present, the medical record room staff just finishing some small amount of paper, and the rest you can check in online, so that medical records from a single medical record room staff in order to work gradually freed to focus on the inner of Medical Records quality of management, the number of personnel is also reduced from the previous 5 to the present two.
3. To reduce the nursing workload of office clerks
Take care and office clerks original order by a doctor after another in the medical process of medical instruments, printing or writing, the patient's informed consent, inspection, test departments gradually returned to the report card, the nursing process gradually produced a single medical advice, treatment orders, vital signs sheets, etc., work load significantly, and prone to error. After the electronic medical record storage, care to alleviate a lot of office clerical work, save the day care office clerks calculate two hours, all hospital wards in 36 nursing can streamline nearly 10 people.
4. To ensure that medical records storage media and information security
Paper medical record not only needs some storage space, and medical records kept in kind, there are some security risks, such as fire, moisture, mildew and so on. Electronic Medical Records Storage Medical Records can be backed up after the entities have fundamental change, making it possible to be preserved; on the other hand also enhanced the security of medical record information to prevent information leakage, tampering and theft.
5. Improve the discharge rate of medical record three-day archive
Medical staff on the medical history will not repeat printing, thus reducing the discharge of medical record filing procedures, so that hospital medical record filing rate over the previous three days had significantly improved. Before and after implementation compared with the same three-day hospital medical record filing rate from 86.97% to 96.66% increase and improve range of measures than any obvious.
The basic conditions for paperless storage
1. Integrity
A variety of development tools known medical history can not be the same time the text, images, tests, electrophysiology, etc. can come together and solve the medical records data integrity issues. The patient's medical records are records, including the following four parts: First, hand-written medical personnel, and second, the information automatically generated, three is a natural information, diagnosis and treatment of four was recorded. We index information to all their different form of electronic records, primary index number in the hospital under the form of virtual printing PDF files, to achieve the purpose of complete medical records.
2. Timely accuracy
On vital signs, electrophysiology, pathology, PACS, LIS, endoscope and other records of the formation of different interfaces and methods are required by different software in a timely manner the formation of electronic records; on the objective examination of test results and disease evolution, at a specified time node recorded, either automatically generated or the medical staff's treatment of written records, require timely and accurate, can withstand the patient, hospital quality control and inspection laws.
3. Non-repudiation
Handwritten signature database technology and step by step level can not be changed after submission, and process real-time disclosure, medical records, has made paperless electronic medical records storage will no longer be a problem. To display the watermark on the illegal printing techniques, so that the illegal termination and non-privileged users can not access to clean print of medical instruments, but also "special seal affixed medical instruments as a legal basis can be" prompted to resolve disputes only One version.
February 2010, the Ministry of Health launched the "basic norms of electronic medical records (trial)", the establishment of hospital electronic medical records, use, preservation and management of acts.
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