Method for recording and transmitting electronic medical record file

Abstract

The invention provides a method for recording and transmitting an electronic medical record file. The method comprises the following steps of: firstly, arranging more than one recording units, wherein each of the recording units comprises a computer host, a keyboard or a handwriting board and a network interface; arranging at least one main server which is connected with the recording units through network transmission cables; and arranging a standardized recording module in the computer host of each recording unit, wherein the standardized recording module comprises a medical record model; the medical record format of the medical record model comprises a medical record sheet editor; and the medical record model comprises 100 models of branch hospitalized medical records in medicinal hospitals and covers branches set in large and extra-large hospitals. The method for recording and transmitting the electronic medical record file can be applicable to electronic recording, transmission and final management of the medical records of small, middle-sized and large hospitals.

Description

technical field [0001] The present invention relates to the technology of using computer hardware to record and transmit medical record information, in particular to the method of using multiple computers to form a digital control system and using the digital control system to record medical record information, transmit medical record information and manage medical record information. Background technique [0002] In the prior art, there are various file management systems. [0003] However, digital control systems for recording, transmitting, and processing medical record information are rarely seen in the prior art. Medical records established with digital control systems are called electronic medical records; electronic medical records have their own particularities. [0004] Particularity of electronic medical records: [0005] 1. The entry of electronic medical records shall follow the principles of objectivity, authenticity, accuracy, timeliness and completeness; [...

AI Technical Summary

Problems solved by technology

[0020]1. The legal effect is not strong: after the implementation of electronic medical records, manual writing is canceled, and all patient information must be printed by machine, and the continuous printing function cannot be realized at present , can not guarantee to print and sign at any time, the unprinted medical records and the printed medical records can be modified, deleted and supplemented without leaving any traces. , lack of authenticity, real-time and legal authority, this is a problem worthy of attention; with the enhancement of people's legal awareness and self-protection awareness, medical records are used in medical malpractice, medical dispute evidence collection, public prosecution law filing, traffic accident, social medical treatment The legal role in insurance, disability identification, inheritance and other cases is becoming more and more important; if there are no rigid regulations on the operating procedures of electronic medical records and strong technical guarantees, doctors will not pay attention to the legal role of medical records. Once medical disputes or judicial disputes occur For legal-related events such as evidence collection, medical records will become an excuse for patients to threaten the hospital and become the focus of medical disputes, which will put doctors and hospitals in a very passive position and even bear legal responsibility;

[0021]2. The assimilation phenomenon is relatively prominent: the computer has a powerful paste and copy function for the medical record text, which is really convenient and convenient for recording repetitive medical record content. It is fast, saves time, reduces manual labor, and improves work efficiency; however, a small number of doctors are not strict with themselves, do not seriously ask patients about medical history and physical examination, use a large number of ready-made templates, and conduct simple and simple medical examinations for the same disease or even different diseases. A lot of copying and pasting, so that the unique "template" phenomenon in electronic medical records appears; this kind of "cut corners" medical records cannot fully and truly reflect the patient's medical history, and the characteristics, symptoms and signs of the cases are surprisingly similar, and the course records are also the content Not detailed, lack of analysis and discussion of "journal account"; this is not only a technical operation and application of electronic medical records, but also a manifestation of the decline in the quality of medical records, which will definitely have a great negative impact on the quality of medical care; if our medical records are all If it becomes a simple copy, as far as there is no medical quality, it will lose the important value of medical records in scientific research, teaching, law, management, etc.;

[0022]3. Confidentiality is not strong: medical records are all original records of patients during hospitalization, and are a kind of medical secrets with strict confidentiality; and quality control personnel have the right to review medical records; at present, although the No. 1 Military Doctor Workstation has set up a user name and password for each doctor, and has the function of modifying at any time, there are still large loopholes in confidentiality; because The entire content of a medical record is usually not necessarily completed by the treating doctor; for example, when a patient’s condition changes and needs to be recorded, the treating doctor is not in place, and only the doctor on duty writes the medical course record, and the doctor’s username and password cannot be kept secret from the doctor on duty; Department directors or superior doctors have the responsibility and power to modify the medical records of subordinate doctors, and must disclose their user names and passwords when they need to be modified; interns can only use the user names and passwords of teaching doctors when writing medical records. The actual publicization of usernames and passwords is in a situation where there is no secrecy; if the doctors in the department do not have a strong sense of confidentiality and the management of usernames and passwords is not strict, over time it is very likely that modifications, deletions, online theft, random printing, etc. will occur; It will also bring hidden dangers of medical disputes;

[0023]4. Difficulties in medical record management: At present, the management of electronic medical records is still far from perfect. According to relevant regulations, electronic medical records must be converted into paper medical records after completion. The synchronous operation mode of "paper type" and "paper type" has brought many disadvantages to the management of medical records. Many doctors rely too much on the electronicization of medical records, while ignoring the requirements of traditional paper medical record management; for example, printing is not timely, many The patient’s admission records and disease course records have already been completed, but they cannot be printed in time, so that the superior doctors’ rounds, case discussions, consultations, and various quality inspections and monitoring cannot be carried out effectively; Or due to the low level of entry, various records cannot be completed in time, which also directly affects the smooth development of various medical work; Timely, the format is not uniform, and the content is too simplified; the phenomenon of missing important diagnosis and treatment results analysis and major rescue records is also serious

In addition, the use of electronic medical records does not pay attention to saving, and the waste of consumable materials is serious

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