Denomination, Format, and Content of Medical Record

Abstract

The broad inpatient medical record includes all kinds of inpatient data regarding the medical activities for the patient, while the narrow one is medical files that summarize, analyze, and sort the relevant data obtained from inquiries, physical examinations, auxiliary examinations, diagnoses, treatments, etc., mainly including complete medical record, admission record, re- or multi-admission record, admission and discharge record within 24 h, admission and death record within 24 h, general and special progress records, all kinds of informed consent forms, and critical illness notice.

Appendix

1.1 Electronic Medical Record

1.1.1 Concept and Content

Electronic medical record (EMR) is to have paperwork of traditional medical record filled out electronically by computer software and hardware. It records all information related to the patient’s diagnoses and treatments, and has data functions of gathering, recording, processing, storing, managing, transferring, etc. It is a digitalized medical service for outpatients and inpatients, used as a type of clinical resource to record the complete and detailed information of patients. It is an inevitable product of the application of information and internet technology in medical field. Moreover, it has become an irresistible trend to have EMR in the computer network administration system in hospitals. The paper medical record has been named as a traditional medical record after introduction of the concept of EMR. The main contents of EMR, according to its basic concept and framework, include several parts of basic medical service, such as abstract of medical record, outpatient and emergency medical record, inpatient medical record, health examination, referral record, legal medical certification and report, messages from the medical institution, etc.

1.1.2 Basic Requirement

EMR must conform to requirements of all kinds of legislations and regulations in China. All information of objective contents and integral data must be inputted by medical staff, with traces left for all modified and deleted data. EMR system should have functions of data ultilization, such as (a) reviewing previous medical records of inpatients, outpatients, and emergency patients; (b) printing all kinds of contents of medical records; (c) supporting statistical analyses and automatically outputting statistical forms; (d) connected to other systems to form an integral hospital information system; etc. In addition, this system should be high-efficiency, secure and reliable, with all processes in accordance with the requirements of medical regulations.

1.1.3 Development Trend

Compared with traditional medical record, EMR has a lot of advantages, such as information integration, information sharing and interaction, information intellectualization, saving resources, etc. However, there are still many problems that need resolved, such as EMR standardization, legal responsibility and system security. “Basic Framework and Data Standards for Electronic Medical Records” (exposure draft) was issued by The National Health and Family Planning Commission of China in August 2009, which established the basic framework and data standards for EMR for the first time. Six parts are included: preface, basic concepts and systemic framework, basic contents and information sources, information models, standards for data sets and elements, as well as basic models and data standards. These have preliminarily solved problems related to the national standardization of EMR. However, individual standard in EMR still requires continuous supplementation and improvement. Only when problems are continuously explored, discovered and solved, can EMR have a greater effect on clinical practice .