Construction and promotion of structured medical records
EMR extraction and conversion vs. Structured EMR
Field design of structured medical records
Development characteristics of Chang Gung Memorial Medical Record Architecture
Source management
- Input from source - input in sequence, use at multiple levels
- Standardization - using data dictionaries
Autonomy
- Source design – to meet personalization
- Autonomous form design, independent management and control settings, independent design calculations
Intelligent
- Logical interactive forms, interconnection between data, and advanced search conditions for data
- Library content calibration, search and mapping
Management aspect
- Automatic data collection and statistics, speeding up the timeliness of job signatures
Structured medical record promotion results
The focus and achievements of structured medical records in recent years are:
- 2020: Set promotion goals, which will be promoted by the information promotion branches of each hospital district and monitored and promoted by the Information Promotion Federation.
- 2021: The surgery has reached 100% of the target. Each hospital district selects a model department to promote examination, inpatient and outpatient services, and then promotes the model department to all specialties in the system in parallel.
- January 2022: All demonstration subjects have successively reached the standards, and the target threshold for the demonstration subjects is 100%.
- September 2022: The inspections and hospitalizations in the demonstration department have gradually met the standards, and the whole hospital has been upgraded to 100% monitoring.
Speech to the whole hospital
Live discussion
Template Sharing•Seed Teacher Course
Specialist Counseling
Build a structured medical record platform
Develop specialized medical records based on specialty characteristics
Dictionary combined with data management and control to ensure the quality of medical records
Form execution automatically loads medical data
Platform design supports sharing of medical record forms and information fields
Cross-platform and cross-device planning to enhance mobility
Structured reporting and presentation
Structural improvements to medical disposition reporting
Free text input to structured
Practical application of structured medical records-psychiatry
Using structured medical records to construct a clinical decision support system model
Acute kidney injury (AKI) warning system and clinical decision support
