Constructing A Completely Structured Electronic Patient Record Applicable To Data Gathering In Investigation Of Splenasthenic Syndrome

We have designed and build a data collective system for Spleen and Stomach syndromes from the point of knowledge model taking the form of Electronic Medical Record. The System is constructed with VISUAL BASIC6. 0, VBA, and SQL SERVER2000, under the Client/Server Architecture. The system is composed of the following functional modules: Staff role administration, System login in and login out, Attaching relation administration, Patient registration, Minimum data elements administration, PR and PR template entry and review; PR quantitative audit.We split a patient record with the minimal data elements, defining the relationship between the elements with dynamic arbor structure in order to embody multi-levels bio-medical informatics physics structure and conscious structure in different special area and the individual varieties. Minimal data element definition is implemented by "Knowledge Editor" (KE). The definition involves element data type, value confine, measurement unit, concept term, arbor code, score, role prosperity and trigger of child node in the arbor tree. The trigger mark off a lesser section within the value scope. The entry data locating in this section will trigger off the automatic presentation of the child-node elements. The KE define the EMR template of the first level.By processing the EMR template of the first level, a set of minimal data elements (MDE) constitutes the EMR template of the second level. The process includes keeping in some data element which is not in common use, adding suggestive color to the element, introducing different arbor code and introducing different concept terms, which is necessary for the requirement of speediness entry or which can make caution and complete PR entry crossing different language. Medical staffs must transfer the template of the second level to entry data in a PR.The set of MDE structured the PR data in the transverse section at a certain occasion. To implements data structure on the portrait section, our system organizes each individual clinical event taking the form of time-orient according to the order of "Event Occurring Time".On the systematic interface, our system use the text field in WORD 2000 application to organize data elements in form of natural text paragraphs, provides interface container for elements of different data type.Our System provides quantifiable collated evaluation function for the PR being entried base on SDE. Score (power) of each element is defined in KE. Score of PR is calculated via measuring deviation against the "golden standard" PR. To guarantee the safety of PR data, our system provides data accessing three-parts authorization among "medical clerk" and "clinical-staff" and "PR administrator" and two-class data accessing authorization between junior and senior.Creativity of this study lies in PR Para graphic splitting in time order, minimum granularity design of PR data elements; multi-arbor framework design; automatically triggered presenting of data elements; natural-language-style...