The application of the computer-based patient record system in hospital information system / 医学研究生学报

Based on the practical running state of the computer-based patient record system in Nanjing General Hospital of Nanjing Military Command,PLA,this paper elaborated the soft structure? function and characteristics of the computer-based patient record system in detail,and the technical implement method of the computer-based patient record system was also introduced in the paper,which has the guidance significance for developing the computer-based patient record system in other hospital.

Development of Psychiatric Computerized Medical Records System / 신경정신의학

OBJECTIVES: Computer-based patient record (CPR, Electronic medical record) improves the quality of medical record which reflects the quality of clinical practice. It provides more efficient and convenient way of input, retrieval, storage, communication and management of medical data. The purpose of this study was to develop a practical domestic model and theoretical basis for CPR for psychiatric patients. This model can be applied in other clinical departments. METHODS: The contents and types of items to be included in the data-base were determined through consensus meetings of investigators on the basis of our previous works on the 'comprehensive assessment of symptoms and history in psychiatric disorders' and analysis of structure and items of medical records. The computer program(Asan Medical Center Psychiatric Information System, APIS, version 1.0) was developed using Oracle 7-3-4, Power builder 4.0, Hangul Windows NT and TCP/IP as a programming, development tools, system operation and transmission protocol. RESULTS: The characteristics of APIS are as follows. 1) APIS ensures comprehensive and high quality psychiatric record through combinations of free-text and structured data format and through many available 'help pop-up windows' of required items for better documentations. 2) APIS provides convenient and efficient ways of data input, particularly for narrative input of texts, with various tools such as 'template copy', various 'pop-up lists for block or phrase copy'. 3) APIS enables users to create and modify the template files or scales for research. 4) APIS which adopted principles of POMR (Problem Oriented Medical Record) makes cumbersome management of problem titles very convenient 5) APIS also provides additional statistics necessary for hospital audit and managements as well as mail communication and schedule management of department. 6) Access to APIS requires authorized ID and password where several levels of privileges (view only, edit allowed, master) are assigned to secure the data. And also modification of data was not allowed after completion of medical record except by persons with master ID. User's password and the data before modification can be traced. CONCLUSIONS: Our study results demonstrate the practical model and theoretical basis for CPR for psychiatric patients. We believe that this model and methods contained in this program can also be applied for developments of CPR for other clinical departments.

A development of Entity-Relationship Model on Computer Based Patient Record / 대한의료정보학회지

The purpose of this study presents the model of Entity-Relationship Diagram on CPR. The specific purpose of this study as follows; The first goal is to identify the content and logical structure of the CPR. The second goal is to define the relationship of data coming from diverse systems(for example, clinical laboratory information systems, order entry systems) and the data stored in the CPR. The 22 kinds forms on Medical Record were collected from 10 hospitals. The Clinical heart of the CPR is the core of entities: patient, provider, problem, encounter order, service, history, etc.

Practical digitalized patient records control / 中华医院管理杂志

Objective The objective of digitalized patient records control is to meet some new demands set on patient records control under the new circumstances. Methods A computer system for digitalized patient records control and supporting processing, management and applications setups were established. Results The system put the contents of the patient records into various categories with difierent standards and designed relatively strict means of authorization. It rendered patient records easier to use and their control more strict, making it possible to make general use of the records without access to the original documents. As a result, data loss was avoided, authority over the data was put under control, data sharing was provided, and full and convenient use of data was realized. Conclusion Digitalized patient records control, a form of shaping computer-based patient records before the latter fully comes into being, enhances the efficiency of patient records application and reduces the pressure of paper records storage. It is a practical and effective way of controlling patient records.

Ways of implementing true and practical computer-based patient records / 中华医院管理杂志

Computer based patient records(CPR) are an inevitable trend in the process of building digital hospitals. The authors offer an analysis of the implications and functions of CPR, arguing that in essence computer based patient records are first of all "records", which must carry all the attributes of traditional records and that their "electronic" form of expression and means of implementation are only of secondary importance. The following viewpoints are set forth: ①management of CPR data by means of databases rather than the text mode; ②adoption of authorization by doctors and the scheme of security control; ③implementation of the supplementary subensemble scheme.

PKI-based security for computer-based patient record information system / 医疗卫生装备

Public Key Infrastructure (PKI) can provides a series of security services for computer-based patient record information system. This paper discusses the application of PKI to the security of computer-based patient record information system.