1. Introduction
This system is mainly for hospital doctors and nurses, and provides functions such as writing, saving, modifying and printing electronic medical records of inpatients. This system is based on the cloud SaaS service method, accessing and using the system functions through a browser, providing an integrated electronic medical record solution for online production, management and use of electronic medical records, and providing support for the development of electronic medical record business in hospitals.
2. Overall framework
1. Technology selection
The system adopts the front-end and back-end separation mode for development and deployment.
Front-end technology selection: native HTML, JS, CSS, Jquery, BootStrap, layui, Swf plug-in, Clipboard, Echarts, PagedJS printing plug-in, Prince printing plug-in, Wkhtmltopdf printing plug-in, etc.
Back-end technology selection: SpringBoot framework, Mybatis-Plus, WebSocket, Stomp, Vintage-Engine page analysis template engine, Thymeleaf page analysis template engine, Fileupload file upload component, etc.
Database: MySQL database.
2. Frame structure diagram
3. System advantages
The integrated electronic medical record system is based on the cloud SaaS service and is provided by B/S (Browser/Server) architecture. Users can access it through a browser without paying attention to system deployment, maintenance, upgrade and other issues. The system fully considers the template The design method of customization, configuration and expansion covers the entire process from the creation of electronic medical record templates to management and use in medical institutions. In addition to realizing online production of electronic medical record templates with rich content, pictures and texts, and complete functions, the system can also be used to customize personalized, practical, and characteristic electronic medical record templates according to the characteristics of medical institutions and according to the needs of different businesses; the system can Unified and centralized management of electronic medical record templates, general electronic medical record templates can be directly provided to different medical institutions for direct use, avoiding repeated production; it provides fully functional control elements to realize the automatic data acquisition function of electronic medical records in business use, It simplifies manual filling in a large number of reports.
4. Application scenarios of electronic medical record editor
Application scenarios include: electronic medical record writing, body temperature sheet entry, platform-wide information collection, inspection and inspection reports, adverse event reporting, etc.
In addition, the electronic medical record editor software is also suitable for editing medical records at doctor workstations, inputting nursing records at nurse workstations, editing and printing PASC/LIS/RIS reports, medical record homepages, discharge summaries, medical course records, surgical records, various informed letters, rehabilitation And scales for psychiatry, form interfaces for clinical pathways, etc.
These application scenarios all involve the needs of medical document editing, so the electronic medical record editor software has a wide range of application values in these scenarios.
5. Hamilton Depression Scale (HAMD) Template
Hamilton Depression Scale (Hamilton Depression Scale, HAMD) is a scale compiled by Hamilton in 1960, which is the most commonly used scale in clinical assessment of depression. This scale has 17 items, 21 items and 24 items in 3 versions.
6. Electronic medical record system is a special medical system. The hospital electronically records the patient's medical information through the electronic medical record, including: home page, medical course record, inspection and test results, doctor's order, operation record, nursing record, etc., which includes both structured information and unstructured free text. There is also graphic image information. It involves the collection, storage, transmission, quality control, statistics and utilization of patient information.
7. Electronic medical records are an important part of informatization construction and one of the important basis for medical quality management. Complete, timely and high-quality electronic medical records can not only promote the refinement of medical quality management, but also provide an important reference for improving the quality of public health.
The following is a brief introduction to the electronic medical record subsystem of the cloud HIS system. The electronic medical record system is developed and deployed in a front-end and back-end separation mode. The B/S version of the electronic medical record system supports four levels of electronic medical records. Both the cloud HIS and the electronic medical record system have independent intellectual property rights.
Electronic medical record editor, referred to as EMRE (EMR Editor), is the core key basic technology of the electronic medical record system. It has become a specialized submarket within the larger healthcare information technology (HIT) market.
2. Function introduction:
1. Merge preview:
This function is only used during the hospitalization process. The purpose is to aggregate all the medical records in the hospitalization process of a patient to form a large medical record that can be printed. Support saving and control editing functions.
2. Ordinary medical records:
In this mode, you can create, edit, preview, save, and print the medical record data of a single patient. Operations related to medical records.
3. Custom templates:
template editing: medical record templates involved in medical institutions can be designed and produced as required, and this operation can be realized through the 'editing' function in the medical record template of the template management sub-module of the operation and maintenance operation subsystem.
Save as a template: The doctor saves the current medical record as a template and sets it as the doctor's personal medical record template, so that the same medical record of the same patient can be reused later.
4. Data synchronization:
it exists for data sharing between different medical records of the same patient. The synchronization function is mainly for 6 types of controls in the medical records (outline elements, macro elements, date elements, selection elements, radio elements, check element) data for synchronization.
5. Medical record printing:
regular printing, PDF printing.
6. Auxiliary input:
Auxiliary input provides convenient operations such as current date, current time, and doctor's signature.
7. Page layout:
adjust paper orientation and size; set margins and printing methods.
8. Export PDF:
Directly export any current medical records (general medical records, customized personal templates, merge preview, historical medical records) into PDF and download to the local.
3. Editor usage process
Composition and use of template editing and preview tools
The template editing and preview interface consists of the menu bar, tool bar and content editing area from top to bottom. Electronic medical record template editor.
1. File menu
Under the file menu, there are two types of tools: file management and open, which mainly realize the loading, saving and downloading of medical records.
●File management tools include:
■Open xml: open the xml file downloaded through the editor;
■Download xml: save the edited medical record document in xml format as a local xml file.
●Opening tools include:
■Open: open the original medical record file, the supported file format is .doc.docx;
■Save: save the edited medical record file to the database.
2. Edit menu
The edit menu provides four types of tools: history, clipboard, font, and paragraph, to adjust and optimize the font, format, style, etc. related to the content of the document encountered during the editing process of the medical record document.
●Historical record tools include:
■Draft box: store the edited document before opening operation;
■Undo: undo the previous operation;
■Restore: restore the undone operation.
●Clipboard tools include:
■Copy: copy the selected content;
■Cut: cut the selected content;
■Paste: paste the copied or cut content to the current position.
●Font tools include:
■Style: change the font style of the selected text;
■Clear Format: clear the format of the selected text;
■Automatic Format: clear the paragraph format of the text
; Selected text;
■Size: change the size of the selected text;
■Increase: enlarge the selected text by one level;
■Reduce: shrink the selected text by one level
;
■Subscript: move the cursor to the lower right corner of the previous text to add content;
■Bold: display the selected text in bold; ■Tilt
: display the selected text obliquely
; Separation line;
■Underline: A horizontal line is displayed at the bottom of the selected text;
■Strikethrough: A horizontal line is displayed in the middle of the selected text;
■Text color: Change the color of the selected text, click the inverted triangle next to the icon to select the color;
■Background color: Change the selected text The background color of the text, click the inverted triangle next to the icon to select a color.
●Paragraph tools include:
■Align Left: Align the selected paragraph to the left;
■Align Center: Align the selected paragraph at the center; ■Align Right: Align the selected
paragraph to the right;
Side alignment;
■Citation: indent the selected paragraphs to the left and right;
■Increase indentation: indent the selected paragraphs to the right as a whole;
■Decrease indentation: indent the selected paragraphs to the left as a whole;
■Bullets: add hollow circle/solid circle/solid square symbols
to the selected paragraphs; ■Sequential numbering: add Arabic/Roman/English alphabetical numbers to the selected paragraphs ;
■Before paragraph: set the distance between the selected paragraph and the previous paragraph;
■Paragraph back distance: set the distance between the selected paragraph and the previous paragraph;
■Line height: set the height of the line in the paragraph.
3. Insert menu
The Insert menu provides insert tools for page breaks, characters, links, pictures, maps, codes, tables, formulas, and comments, enabling the insertion of different elements.
●Page break tool: Click to insert a page break symbol, and the content after the page break will be displayed on the next page.
●Character tools: insert specific characters. Click to open the character dialog box, select the desired character (including special characters, Roman characters, math characters, Japanese characters, Greek letters, Russian characters, pinyin letters, English phonetic symbols and others), and click the desired character to insert the character into the cursor Location.
●Link tools include:
■Add link: Add link information for the selected text. Click to pop up the Add Link dialog box, click the [OK] button in the dialog box to add a link successfully, and the link text is displayed in blue and underlined; ■Modify
Link: Modify the link information for the text that has been added to the link, and the operation after clicking is the same as adding a link;
■Cancel link: cancel the connection information of the added link text.
4. Form menu
The table menu provides table, merged cells, alignment direction and table line style tools to realize the function of making different types of tables and the layout of elements in the table.
●Table tools include:
■Insert table: insert a table with the specified number of rows and columns at the cursor position in the content editing area;
■Delete table: delete the inserted table;
■Insert row: insert a row in the table, and insert a new row at the cursor Above the row where the cursor is located;
■Insert column: insert a column in the table, and insert a new column to the left of the column where the cursor is;
■Delete row: delete the row where the cursor is;
■Delete column: delete the column where the cursor is.
●Merge cells tools include:
■Merge cells: Merge selected cells (more than two);
■Merge cells down: Merge the cell where the cursor is with the cell below;
■Merge cells to the right : Merge the cell where the cursor is located with the cell to the right;
■Split cell: restore the merged cell where the cursor is, and restore both rows and columns;
■Split cell into columns: merge the cell where the cursor is The cells in the list are restored by column;
■Split cells into rows: restore the merged cell where the cursor is located by row.
●Align direction tools include:
■Align top: align the elements in the cell vertically with the top of the grid;
■Center vertically: align the elements in the cell vertically with the middle of the grid
; The elements in the cell are displayed on the same level with the bottom of the grid
in the vertical direction; ■Left alignment: the elements in the cell are displayed on the same level with the left side of the
grid in the horizontal direction;
■Right Alignment: Display the elements in the cell vertically in line with the right side of the grid.
Table line style tools include:
Table style: set the display style of table lines;
click this icon, a drop-down menu will pop up, including three options: hide table lines, set solid lines and set dashed lines, click the options to hide and solid lines respectively Display and dotted line display table lines;
■Bottom line: display the bottom line of the selected cell as a solid line;
■Upper line: display the top line of the selected cell as a solid line;
■Left line: display the selected cell Display the left line of the cell as a solid line;
■Right frame line: display the right line of the selected cell as a solid line;
5. View menu
The view menu provides table of contents, comments, revisions, preview document tools, and provides view display functions.
●Category Tool: When the content in the content editing area is long, the directory can be automatically generated according to the serial number arrangement, and clicking the display directory icon will display the directory at the position of the cursor.
●Annotation tool: used to display/hide inserted annotations.
●Preview document: preview edited medical record document.
6. Tools menu
The Tools menu includes Draftbox, Print, Search, and Word Count tools, as shown, providing various accessibility features.
●Printing tools include:
■Common printing: directly print edited medical records;
■Advanced printing: add the function of continuous printing on the basis of ordinary printing;
7. Medical record control menu
The medical record control provides a new template control tool, and provides various template controls required for making medical records.
●The new control tools include:
■Outline element: add the defined label field of the medical record module to the electronic medical record;
■macro element: add the defined label field and the corresponding key value to the electronic medical record, this element can be obtained automatically in the business system Key value filling;
■Date element: add a defined date label field and corresponding key value to the electronic medical record, this element can automatically obtain the system date key value filling in the business system; the operation method is similar to the macro element operation; ■Select
element : Add a defined selection label field and the corresponding option value to the electronic medical record. This element can automatically obtain the corresponding option in the business system and select it in the form of a drop-down menu; the operation method is similar to the operation of the macro element
; Add the defined selection label field and the corresponding option value to the medical record. This element can automatically obtain the corresponding option in the business system and add a radio control in front of each option to provide a single option; the operation method is similar to the operation of the macro element; multi-select
element : Add a defined selection tag field and the corresponding option value to the electronic medical record. This element can automatically obtain the corresponding option in the business system and add a multi-select control before each option to provide multiple choices; the operation method is similar to the operation of the macro element.
●Customized control defines the control name and control value for the user. After the custom is saved, it has the same function as the predefined control
8. Page layout menu
●Paper Selection: Including paper orientation and paper size.
■Paper Orientation: You can choose whether to print the paper in landscape or portrait orientation.
■Paper size: You can choose the commonly used paper size.
●Margin: Adjust the paper margin when printing.
■Margin: quickly select the margin defined by the system. Or customize the margins in the input box next to it.
●Print: You can preview the printing effect