The new hospital electronic Medical Record Home page (2012 revision note)

1. "Hospital name" is revised to "name of medical institution" and an "organization Code" project has been added

2. "Medical Payment Method" is revised to "medical pay Method"

3. Added "Health Card number", "Neonatal birth weight", "neonatal admission weight". Added "Live Address" and "phone", "zip" to facilitate patient follow-up and statistics of patient sources and other information

4. Added "Admission pathway"

5. "Ward" is revised to "wards"

6. Increased door (emergency) diagnosis of "disease code".

7. Deletion of "hospital admission", "Admission diagnosis", "confirmed date of admission"

8. Adjust the "discharge diagnosis" form, make full use of the limited layout, add "other diagnostic" fill space. deleted the "Discharge status" section of the table and revised it to the "Hospital admission" project;

"ICD-10" revised to "disease Code"

9. Increased loss, poisoning of the "disease Code"

10. Deletion of "Hospital infection name"

11. Added "pathological diagnosis" of the filling space, increased the "disease Code", "Pathology" project. Medical institutions can, according to the actual medical practice, increase the "Tumor morphology code" and other items appropriately.

12. "Drug allergy", added "have, no" option

13. Removed the Hbsag,hcv-ab,hiv-ab

14. Revise "autopsy" to "autopsy of deceased patient" and advance to first page

15. Adjust the "blood type", RH project to the first page, and modify the content.

16. Revision of "master (deputy principal) physician" to "director (Deputy director) physician", deletion of "Postgraduate intern" signature

17. The "Responsible Nurse" project has been added to meet the needs of the model project on responsibility Nursing Services.

18. The surgery-related items were revised and adjusted in sequence, with the "Operation and operation" revised to "surgery and operation", the "surgical level" project was added, and the "Incision healing grade" was adjusted.

19. Added "Leave the way" related projects

20. Added "no hospitalization plan within 31 days of discharge"

21. Added "Coma Time" for patients with craniocerebral injury.

22. Items such as "surgery, treatment, examination, diagnosis of the first case", "follow-up", "follow-up period", "Teaching case", "transfusion reaction" and "transfusion variety" were removed.

23. The hospital cost statistics project has been adjusted to harmonize standards and facilitate statistical analysis.

The new hospital electronic Medical Record Home page (2012 revision note)