The source code of the subsystem cloud electronic medical record system of the Java version of the SaaS model cloud HIS system. This system adopts the front-end and back-end separation mode for development and deployment, and supports four levels of electronic medical records.
The electronic medical record system mainly provides medical record basis for the inpatient department of the hospital, and assists medical personnel to record, store, manage, transmit and reproduce digital information such as text, charts, graphics, data, images and other digital information generated by means of information technology in the process of medical activities. Medical information is a record of the results of various medical activities.
This system is based on the cloud SaaS service method, accessing and using the system functions through a browser, and providing an integrated electronic medical record solution for online production, management and use of electronic medical records.
1. Features of electronic medical record system:
1. Through electronic information transmission and sharing, optimize the hospital's internal workflow and improve work efficiency.
2. Intelligent templates, fully structured input, support multiple input methods such as fully structured selection, template input, table format, and text.
3. Provide complete, real-time, anytime, anywhere access to patient information for medical staff, which helps to improve medical quality.
2. System function description:
【Medical record management】
Unified management of patient information, after the patient is admitted to the hospital, the electronic medical record platform synchronizes the patient's hospitalization information through the HIS system. Support the modification of basic patient information, patient contact information, and patient hospitalization information.
Provides the function of writing patient medical records, and the system provides a structured template filling method, which not only meets the requirements of the medical record format, but also provides a convenient way for doctors to write medical records, and also provides accurate clinical data for future medical development.
After the patient is discharged from the hospital, the medical record can be submitted to the medical record room after review, and the medical record room will file it.
【Medical record template】
The electronic medical record template maintenance function can flexibly compile the content and style of the structured medical record template, and can define the content of the medical record template.
Users can design templates that meet their own requirements, and can specify the scope of use of the templates, such as templates for the whole hospital, templates for undergraduate departments, and personal templates.
The content of the medical record is a separate description of each symptom and sign, and each element on the medical record template can be retrieved and added to improve the efficiency of medical record data search, which is of great help to clinical scientific research.
【Content template】
The content template mainly includes entry maintenance and element management. The addition of medical record entries and element information is convenient for direct use and addition when editing medical record templates and writing medical records. Entry maintenance is a detailed description of the specific information of the medical record, such as symptoms and signs.
Element management can retrieve and add each element, such as patient basic information, gender, name and other fields. Improve the efficiency and accuracy of medical record writing.
【Medical record management】
The medical records submitted by each department to the medical record room can be archived and preserved, and the medical record room can reject the medical records that do not meet the requirements, and the archived medical records are no longer allowed to be modified. Medical records staff can view all filed and submitted medical records.
【System Management】
System management mainly includes time quality control settings, user authority management, and system parameter management sub-modules.
Time quality control setting can set the time quality control setting for the classification of writing medical records; in order to supervise the writing time limit of each medical record.
Role authority management can maintain the authority of each sub-module. It mainly includes all the current sub-module functions, you can set the corresponding permissions for the corresponding role, and save or cancel the save after selection to take effect.
System parameter management mainly uses the maintenance of the registration code of the medical record writing control.