Medical records management is responsible for the recycling, tidying, classifying, cataloguing, binding, archiving and keeping of the medical records. The information collected will be used for statistics, which mainly includes hospital management, teaching, researching and so on, and it relates to many aspects like the whole hospital medical business, comprehensive benefits, financial revenue and expenditure, construction equipment, personnel structure and energy consumption. The Monitoring and management system of medical records invented by Haitai is based on the current situation of our countries' treatment level of medical record information statistics, and it is developed and designed according to the future needs. The system could not only meet the actual demands of medical records' statistics and management, it also considers the hospital information system's constantly perfection during its development and the developing directions of the information sharing. What's more, the system has broken the traditional management model of the medical records statistics, and established the system software which meets the requirements of modern hospital information management.
Functions and Features
Unified and standard dictionary
The establishment of unified and standard encoding dictionary like department dictionary, diagnostic dictionary (ICD-10), surgery and operation dictionary could make sure that the data captured from EMR and HIS system or the data collected automatically by medical record system both obey the unified encoding dictionary. All the data is standard and available which does not need secondary transformation to improve the precision of the data.
Accurate and timely data acquisition
The system will establish a unified input path to normalize the data acquisition from the source, and verify the accuracy and logic of the data during acquisition, so that it could avoid the post-modification and artificial coding and make sure that the data is real and effective.Meanwhile the system supports the external data from other systems, and keeps them according to the unified and standardized data format for late-time data's inquiry and statistics.
Multi-angle and multi-dimensional statistics
When the hospital establishes a statistical report system through the medical record system, it could meet the application requirements of myriad statistical reports and provide the basic information that levels of health administration departments need, such as the human resources, material resources, financial resources, basic construction of health agents, medical efficiency and the complication of medical quality, then the hospital's medical development could be known comprehensively and the system could be used for management requirements of medical treatment, quality control, performance and statistics analysis.
Information sharing with Health Administrative Departments
According to Health Administrative Departments' requirements, the medical records system could build the link between hospitals and the report system of sanitary bureau information center, it supports the report of the data like HQMS, DRGs, etc.The system could automatically finish the timely report and storage of single or bulk patient medical records, support the management and monitoring of the medical records data.
Further usage and wide sharing of the data
The establishment of medical records system could realize the statistics and inquiry of clinical and management data, provide standard and unified output and support formats of data derivation. Meanwhile, medical records data could be sent to other information systems in the hospital by connector, so that the health information could be shared in the hospital sufficiently.