T/HENANPA 003-2022 Guidelines for Building an Electronic Medical Record System for Hospitalized Patients

Scope

Main technical content: This standard sets out detailed specifications from three aspects: basic requirements of electronic medical records, data structure and information model of electronic medical records, and content, information sources, and formation methods of electronic medical records. **Basic requirements**: It stipulates that electronic medical records should refer to the three-dimensional conceptual model of electronic medical records in terms of timeline, and the design should balance functionality and practicality. It should also fully consider the pharmaceutical service scenarios of clinical pharmacists. The terms, codes, templates, and data used should comply with the requirements of relevant industry standards and norms. An archiving status should be set, and functions such as query, management, statistics, and printing can be completed in the clinical pharmacist workstation. **Data structure and information model**: It defines the data structure of electronic medical records and the content related to the information model of clinical pharmacy documents. The data structure stipulates that the medical records are mainly composed of clinical pharmacy documents with a certain hierarchical structure, divided into four layers: clinical pharmacy documents, document segments, data groups, and data elements, which are clearly represented by a structural diagram. The role of the clinical pharmacy document information model is to establish a standardized data expression mode and information classification framework for business activity records (i.e., clinical pharmacy documents) with different sources and purposes in electronic medical records, realize the structured expression of clinical pharmacy documents and the scientific archiving of data elements, and facilitate the rapid understanding and sharing of electronic medical record information by users. Clinical pharmacy documents are divided into two parts: document header and document body. The

Development Information

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