Establishment of an electronic medical records system and integration of clinical data / 中华医院管理杂志

ABSTRACT

This paper introduces the implementation of an electronic medical records system and the integration of clinical data in our hospital. The electronic medical records system is grounded on XML based electronic inpatient records and focused on information of patient treatment, which has integrated information of prescriptions , outpatient visits, PACS, medical examination technologies, laboratories, nursing records, reports of infectious diseases and hospital infections, licenses for antibiotics and pharmaceutical repositories, and the clinical data with electronic medical records as the carrier. This system has provided physicians with effective tools for diverse paperless medical records and favorable conditions for diagnosis and treatment, it has improved the work efficiency of physicians, optimized hospital process, minimized errors and improved quality of medical treatment. With the development of real-time quality control of medical records, we have improved efficiency and quality of hospital management.