Hospital Management Software - Medical records of patients are a document that explains all the details about the patient's medical history, the results of diagnostic tests and radiology, pre-and postoperative care, the evolution of the patient's health with medications and follow-up.
If these data are entered correctly and are easily accessible, they will support doctors ' decisions about diagnoses and the correctness of treatment. Medical records are one of the most important aspects that a hospital should take care of to provide proper care to patients and also to comply as a legal institution.
During this article, we will explain the concept of electronic medical records, the importance of the patient's medical file within each hospital, the contents of the patient's medical file, and finally how you can record patient data easily without any errors and electronically
Patient's medical file
The electronic medical record, also called the electronic patient file, is considered the basis in any health system, it provides an overview of the latest information recorded in the patient's medical record such as: personal data, medical history, previous statements and treatments, drug allergies, and others. Electronic medical records (patient file) do not differ much from traditional paper records in their function and purpose, but they differ completely in their nature, properties, possibilities of Use and benefits, they represent a central point for connecting many departments of medical care, and they are distinguished by the accuracy of their content and accessibility through their integration with various information sources. The patient's medical file is a database that includes all patient information and relies on a computer with all its advanced capabilities in storing information, processing and transmitting data via the internet and modern means of communication.The most important uses of medical files within the field of healthcare:
- Facilitating quality patient care
- Provide an effective way to communicate with other medical team members
- Fulfillment of legal and ethical obligations within the medical institution
- Use it as a documentation guide, if inquiries are made about the services and care provided by the medical institution at any time
The most important uses of medical files outside the healthcare field:
Legal issues: the most famous example of this is the Personal Injury Law, where documents related to the patient's health will certainly be necessary for the completion of legal proceedings. Insurance companies ' claims: insurance companies often request medical documents when evaluating claims so that any medical bills match the claims submitted. Medical research and Social Security are also common examples in using the medical file so that they have a full understanding of the patient's health conditionThe importance of the electronic patient file
The patient's medical file has many features, which make every medical institution not to abandon its application:
- Getting rid of paper records that have become a threat to health organizations due to multiple disadvantages, such as: slow movement, difficulty retrieving information, and frequent data losses
- The electronic health record is the meeting point of all systems, because the electronic medical file contains all the medical results, diagnoses and treatments performed for the patient and the medicines given to him
- Provides networking opportunities between individuals and health service delivery teams of doctors, nurses, technicians and administrators
- Electronic medical records contain many information that contribute to the development of scientific research, and also provide medical and administrative reports and statistics that serve the activities of the hospital
- Helps to improve the accuracy and accuracy of the data recorded in the health record
- Helps to improve the quality of health care provided to the patient by providing the necessary information in a timely manner
- Raising the efficiency of health services and saving costs through the rapid exchange of information
- A documented and complete medical record protects the hospital and the doctor from any complaint that may be filed without justification or argument, and thus protects the patient from any negligence or negligence in the care provided to him.
- Medical records are the primary source of reports and statistics submitted to the hospital administration, showing the volume and type of medical services provided to patients.
- The patient's medical file is considered the official document adopted by the hospital when reviewing all medical and nursing procedures and services provided to the patient to ensure their suitability in qualitative and quantitative terms.
- The provision of the electronic medical file to the patient inside the hospital plays a big role in the accreditation of the hospital or the so-called accreditation, which is the recognition by a specialized body that the hospital has met all the conditions, standards and requirements set by the executing medical body.
Components of the electronic patient file
The linkage of the electronic patient file and the integration of its content with other subsystems within hospitals and medical centers can provide healthcare providers with many information, such as: all patient information in an integrated and consistent manner such as: (treatment, medical history, test results, radiographs) The patient's profile in the hospital contains:Personal data of the patient
- Registration form Patient name (Arabic - English)
- Address and phone numbers
- Date of birth
- Gender, marital status and nationality
- National number
- E-mail address
Insurance companies
- The contracted insurance company
- Name of the responsible entity
- Employer data
- The relationship of the patient with the insured
Approvals and authorizations
For any course of treatment that goes beyond routine procedures, it should include such information:
- Diagnosis and chances of recovery
- The course of treatment
- Benefits and risks
- Probability of success
- The dangers of not taking treatment
History of treatment
1. Pathological history
2. Complaints
3. Surgical history
4. Therapeutic history
5. Dates of birth (for women)
6. Physical examination and vital signs
Radiology reports
Recording the results of radiological tests
Doctor's orders and transfers between clinics
The doctor orders the patient to take certain tests and tests, or to continue taking certain medications, adhere to certain prescriptions and follow up on time.
List of medicines
All medications, whether prescribed or taken without a prescription, including dosage, method of administration and schedule.
Patient confidentiality
- Each medical office has a responsibility to their patients to maintain the privacy and security of their personal information
- Establish policies for checking access permissions, controlling equipment and dealing with visitors
- Develop and submit documentation on how the medical office can help protect health information
- Create a unique user profile including passwords and PIN numbers
The patient's medical file with the hospital management program
It is an integrated web system that can be used on all devices, enabling the hospital and the medical institution to monitor patients, operations, account management, contracting companies, personnel affairs and all departments within the medical institution.
Crystal View helps you manage many departments within the hospital, such as :
Patient affairs:
You can manage all the patients ' affairs, starting from their admission to the Medical Center to the end of their treatment, including bills, treatment, reservations, tests, radiology, re-examination and all their expenses.Personnel affairs:
Help you manage employees, record discounts, bonuses, salaries, allowances, register insurances, add employee attachments.
Account management:
Through it, you can manage hospital or medical center accounts, such as recording expenses, refunds, losses, sales and purchases, you can also make an account tree, add storage, banks, cost centers, receipts and disbursements, in addition to transaction reports, audit balance and receipts.
Report management:
You can see booking reports, Patient Services report, patient profile, revenue reports by Doctor, billing Summary Report, Corporate patient data, analysis and patient reports.
Features of the Crystal View Hospital Management Program for the patient's medical file :
Ease of communication between the work of different medical departments through the system so that the electronic medical file of the patient is the meeting point of these departments, everything that is provided to the patient from medical services, pharmacy, radiology and others is recorded in the patient file, which makes all units work with each other more easily. It provides services for recording patient data, coordinating appointments optimally, following up the patient's health history and providing all the necessary services to the medical staff in a unified system in order to provide the best service to the patient and the doctor at the same time. The system also contains features that help the medical staff to make medical clinical decisions in order to provide patient care with minimal risksWhat does our program provide in the medical file :
- Provision of technological infrastructure in medical institutions
- The results of clinical, laboratory, diagnostic and radiological examinations performed on the patient
- The observations of the medical team, the extent of improvement in his condition, the negative and positive changes that have occurred, and his response to treatment through diagnostic and treatment plans
- The program provides an easy-to-use user interface with an attractive design, which helps to provide a distinctive customer experience, and the system also provides many ways to easily navigate and extract / save information at any time
- View patient data, patient history, including the main problem, changes that have occurred to the patient, radiology, complete examinations, chronic diseases, radiology, analyzes, previous patient statements, patient attachments from X-ray images, treatment received by the patient, its results and recommendations
- The program provides a mobile application for patients on Android and iPhone devices that helps patients to view their full medical file, data, statements, reservations, clinic transfers, diagnostics and doctors ' comments, radiology and analyzes, and many other features and services available to the patient through the phone application
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