Research And Implement Of Clinical Records Management Information System

Electronic medical record(EMR) is the core of hospital information system construction and regional health information sharing. It is important in enhancing the quality of treatment, work efficiency and management level. EMR stores the abundant texts, pictures and vocal information in medical activity. The implementation of EMR is based on the electronic medical records management system, it can realize collection, processing, transmission and sharing of medical information, but also includes prolific medical knowledge and intelligent assisting medical service.The thesis first introduces electronic medical record simply, divides the system modules of the electronic medical record system through the analysis of hospital practice, and proposes to build interactive electronic medical record system based on XML and SOAP protocol. Then, A XML based in-patient department EMR system is also designed, based upon research on the main tecnology and relevant criteria of the medical industry. This system fulfills the basic requirements including structural entry, inquiry, audit, reinput and authoratitive management, etc.Due to the lagging of standardization of medical information, the domestic development of EMR currently is slow. Different expressions and transferring format hinders the efficient exchange of EMR. Thus, this research mainly focuses on three aspects: the structural entry of EMR; the generation of EMR in XML format which is consistent with the medical industry standard CDA; the construction of SOAP-based exchange system of EMR. This thesis elaborates the designing and implementing of structural entry of EMR, the generating, transforming, saving and inquiring of XML-based CDA medical documents, the realization of client and server in specific. The security of the transferring of EMR is also discusssed in this thesis.