Electronic medical records are mainly aimed at doctors and nurses in hospital institutions, providing functions such as writing, saving, modifying, and printing electronic medical records for inpatients. This system is based on the cloud SaaS service method, accesses and uses system functions through a browser, provides an integrated electronic medical record solution for online production, management and use of electronic medical records, and provides effective support for the development of electronic medical records business of medical institutions.
The electronic medical record editor is extremely flexible. It can be embedded into the hospital HIS system and used as a built-in editing tool for multiple modules. It can also be used independently to cooperate with third-party business vendors to provide them with medical record writing functions. Make full use of the editor's capabilities.
1. Introduction to the functions of electronic medical record editor
Realize medical record editing at the doctor's workstation, nursing record entry at the nurse's workstation, report editing and printing, medical record home page, discharge summary, disease course records, operation records, various informed letters, scales for rehabilitation and psychiatry, and form interfaces for clinical pathways, etc. .
The editor has functions such as basic style layout, multimedia resource upload, automatic synchronization of patient medical record information, and automatic calculation of nursing form data, making the operations of medical staff simpler and more flexible, and providing a better interactive experience for medical staff.
The editor supports check, radio selection, drop-down, text input box and other functions, which can realize the structuring of document data, effectively ensure the strong interoperability of patient data information, as well as data accuracy, standardize the entry and storage of patient data, and allow References between data become possible.
Medical staff can also modify the text format as needed through the editor, including complex table layout, cell merging, table nesting, mixed graphics and text, headers and footers, annotations, etc., to meet the multi-scenario writing needs of medical staff.
Front-end technology selection:
Native HTML, JS, CSS, Jquery, BootStrap, layui, Swf plug-in, Clipboard 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 parsing template engine, Thymeleaf page parsing template engine, Fileupload file upload component, etc.
database:
MySQL database
♦The electronic medical record editor is developed and deployed using the front-end and back-end separation model.
2. Electronic medical record template production process
•The production of electronic medical records is the process of using template editing and preview tools according to the characteristics of medical institutions and different business needs, and comprehensively using tool modules to create personalized, practical, and characteristic electronic medical record templates.
The production process is divided into the following steps:
1. Clarify the type of medical records: Determine the type of electronic medical records according to business direction and purpose;
2. Determine the content of the medical record: Determine the name, constituent elements, and required content of the medical record;
3. Design medical record layout: content distribution, paragraph arrangement, table format, font size, style, etc.;
3. Management and use of electronic medical record templates
•The newly created electronic medical record is added to the medical record template list of the corresponding institution. It is enabled by default, that is, the integrated electronic medical record system corresponding to the institution can directly call the template to run related services. Operation and management users can manage existing medical record templates, query, re-edit, deactivate/enable, and delete existing medical record templates.
4. Process for medical staff to use electronic medical records
1. Create a new medical record
•Right-click the medical record tree, click the [Add] button, a medical record list will pop up, select the medical record you want to create in the medical record list, and click OK to create a new medical record.
2.Write medical records
•Click the blue control box and write the corresponding content in the pop-up box. Or write other medical record content directly in the blank text space.
3. Medical record preservation
•After finishing writing, click Save to complete the saving of the medical record.
4. Medical record modification
•After the medical record is saved, the corresponding medical record can be found in the list in the medical record tree. Click to open the medical record again to modify the medical record.
5.Deletion of medical records
•Find the medical record you want to delete in the medical record tree, right-click and select the [Delete] button.
6. Make a medical record template: Make a template according to the content and design in the content identification area.
7. Save the medical record template: Save the template for use after completion.
