Design And Implementation Of A Structured Electronic Medical Record System

Medical record is a essential media of the clinical information, which plays an important role in the clinical, research and teaching. Electronic Medical Record system not only can reduce the burden of hand-written, but also can speed up the usage and utilization of clinical information. In order to release the maximum capacity, Electronic Medical Record system must make the clinical information structured and make the data standardized.This paper takes an exploration and practice for the design and implementation of a structured Electronic Medical Record system. The second chapter analyzes the concept of the Electronic Medical Records system and the importance of making it structured, and introduces and studies some of the domestic and international standards, and then explores some of XML-related technologies. The Third Chapter describes and analyzes the requirements of an Electronic Medical Record system including the user roles, functional requirements and non-functional requirements, and thus determine the technical roadmap for the structured Electronic Medical Record system:using XML Schema to define the hierarchy of The electronic medical records and the significance of the data, storing the electronic medical records in XML format, using the Word template with XML Schema bound as the template of electronic medical records. The fourth chapter describes the overall design of the system, including the overall architecture design and features modular design, data model design and interface design. The fifth chapter details the detailed design and implementation of several core module of the system. These modules can explain the implementation of the technical solution above:the Data Elements Manager and the Clinical Document Hierarchy Manager shows how to define the schema of the data elements and clinical document; the Clinical Document Template Designer shows how to bind a XML Schema onto a Word template to make it as a XML file template; the Medical Records Editor module shows how to edit and display a clinical document in XML format.