Electronic clinical record (Out-patient)

The "Electronic Out-patient Clinical Record" system is the application solution based on the eDocLib ECM platform

Background

Based on the multifunction eDocLib platform developed by Electronic Office Systems company the applied software product for medical institutions of Russia is created. The automated system is intended for maintaining out-patient cards, the organization of acceptance of patients, registration of results of inspection and the course of treatment.

The configuration developed by specialists of SPC Cosmos 2 LLC company (Rostov-on-Don), the partner of EOS Group completely conforms to the approved standards of delivery of health care in Russia and to regulating documents of the Ministry of Health and Social Development of the Russian Federation. Preparation of technical specifications and development of a system concept was carried out under the leadership of members of association of coloproctologists of Russia.

Description and characteristics

Automated system of accounting of patients and control of diagnostics and treatment, working name – AS of eDocLib - "Electronic Clinical Record (Out-patient)" is developed by specialists of SPC Cosmos 2 LLC of Rostov-on-Don (on the basis of the eDocLib ECM system, EOS Group LLC, Moscow) according to Standards of medical care and regulating documents of the Ministry of Health and Social Development of the Russian Federation.

Composition

Formation of the list of basic reference books and document groups for accounting of the patients given on inspection; Maintaining "Out-patient cards" with information about:

• personal data of the patient (full name, Date of birth, Address, Phone),

• complaints/anamnesis of life (associated diseases, the undergone operations, viral infections, allergoanamnez, of inekologicheskiya

• anamnesis, social status of the patient),

• data of survey (objectively, local status),

• diagnoses (the main, accompanying),

• recommendations (the recommended additional examination and consultations of specialists, diet, the mode, medicamentous therapy, manipulations / transactions).

• Prerecording of patients on appointment;
• Maintaining electronic clinical record of patients;
• Attachment to out-patient cards of patients of pictures, photos, other files;
• Ensuring simplicity and fast filling of cards of acceptance of patients;
• Report generation and the printed forms issued to patients about results of inspection and the performed operations/manipulations;
• Formation of statistical reporting for specialists of consulting diagnostic clinic.

Scope

• medical institutions (commercial medical centers, offices).

Report types and printed forms

• The medical certificate about consultation and the conducted examinations;
• Analytical reports (according to diagnoses, on manipulations, by types of inspections and many others).  

System

• Includes all medical and diagnostic aspects of maintaining the outpatient on the basis of the clinical clinical record;
• Provides automation of all stages of medical and diagnostic process in the conditions of clinic and control over quality of its execution;
• Provides implementation of prerecording of patients on appointment, planning of repeated appearances;
• Allows to use specific standard phrases at documentation of outpatient appointment;
• Provides online access to archive of all information on addresses of the patient;
• Gives the chance of preserving in the out-patient clinical record of pictures, photos, etc.;
• Guarantees standardization of maintaining medical documentation;
• Has expanded settings for reduction of technology in compliance with already used in medical institution.

Advantages of professionals

• Simplicity and speed of filling of the clinical record during outpatient appointment, use of specific standard phrases;
• Efficiency and ease of an information access about the patient throughout the period of this address and also to contemporary records on the patient;
• Obtaining medical reporting under required parameters;
• Possibility of operational providing the complete information to the patient about his health;
• Reduction of time for creation of the qualitative medical certificate in full.

Advantages of the patient

• Efficiency of obtaining the conclusions about consultations, including photodocumentation of these inspections;
• Obtaining more complete information volume about the health.

Advantages of the head

• Accomplishment of medical standards of diagnostics;
• Mobility and simplicity of control over quality of diagnostics and treatment of patients;
• Operational obtaining medical reporting under required parameters;
• Simplicity of preparation of state-of-the-art and statistical reviews according to addresses of patients for use in planning of activity of medical institution, the city, region.

Development plans

• Integration with other system for data acquisition about the conducted researches;
• Remote "electronic record" of patients on acceptance;
• The notification on a call on acceptance, on a repeated appearance, for carrying out an additional research;
• Remote additional recommendations and explanations in the section of Recommendation via the interface of access on the website of medical institution.