Research Of The Electronic Medical Record: Information Input And Electronic Realization Of Quality Supervision And Control

Electronic Medical Record (EMR), one of the core contents of medical information management, is the inexorable trend of hospital information process. At present, a patient oriented, highly integrated multi-media Information System (HIS) is under the way in China. The research and utilization of new theories are undertaking. An embrgo form of the Computer Internet Information System has appeared in some hospitals in our country, especially the information system of electronic medical record.But, due to the imperfection of the EMR legislation, co-sharing of information, model medical record and other problems, the structure and criterion of EMR need to be further completed and improved. The medical meaning of traditional medical record is very completed and the only thing we should pay more attentions is the efficiency. How to spare doctors from the heavy routine medical record writings? This is the urgent problem that should be resolved immediately. This paper is focused on the analysis and research of EMR, a virtually electronic monitoring the whole medical-care process.The purposes of this paper are: to learn the present situation of EMR inand out of China; to find out and resolve the problems that exit in the development of EMR; to learn the EMR requirements of doctors and nurses of EMR and propose initial system structure; to discuss the problems of EMR criterion and provide development basis for EMR; to design an EMR system on the basis of the research and practice of modal medical record. All these are aimed at reducing the working burdens and improving the workingefficiency.This paper consists of 5 parts, the 1st part, deals with the meaning, feature and historical significance of EMR and analyze the present situations both in and out of China through literary reviews , and it also analyzes the relations between the "e-Hospital" and EMR. The 2nd part, discusses the main problems of EMR and offers corresponding solutions. The 3rd part gives detailed introductions and explanations on the problem of "what kind of EMR is needed". In this part frame, technical parameters, guiding principals and functions of EMR system are expounded. The 4th part conducts an in-depth research on the criterion of EMR, one of most important issues of EMR. To discuss the criterion of EMR, we should firstly discuss the medical information standard. Many countries have drawn up their own medical information related standards and there are few international medical information standard in the world. In this part, we introduce some noted standards that are closely related to EMR. The research of EMR standards in our country is in developing process. Some main criterion problems in EMR will also be discussed in this part. The 5th part conducts practical researches on EMR and develops a modular record of EMR based on the researches in the above parts. First, it does analysis that takes the hard environment of Military Medicine Number 1 as the background. Second, it has introduced the design principles and system structure and function of model medical record, in which it also gives detailed introductions of criterions and data that will provide high theoretical and practical values in the following clinical practices.