Medical Records Web



Simplified solution schema:

Patient Data

Locations

Record
  • Date
  • Country
  • City
  • District
  • ...

Occupations

Record
  • Date
  • Description
  • ISCO 08
  • ...

Habits/Qualities

Record
  • Date
  • Description
  • ...

Contraindications

Record
  • Date
  • Description
  • ...

Symptoms

Record
  • Date
  • Description
  • Measure
  • ICD-10/11
  • ...

Tests

Record
  • Date
  • Description
  • ICHI
  • CPT
  • ...

Indications

Record
  • Date
  • Temp.,press,...
  • Value
  • ...

Clinic Workflow

Medical Case (previous)

Medical Case (Clinic visit, doctor in charge assigning, ...)

Doctor's Record

Visit / Patients Round / Ambulance / ... other events

  • Patient's data adding/updating
  • Preliminary diagnosis establishing
  • Tests assigning
  • Diagnosis confirmation
  • Treatment assigning
  • Treatment results analyzing
  • Discharging/ transmittal
  • Treatment changing
  • ...
  • CPT

←←←←←←←←

Treatment

Diagnosis 1 (ICD-10/11)
Diagnosis 2 (ICD-10/11)
Diagnosis n (ICD-10/11)
Session
in-patient/
out-patient
Surgery
  • Date
  • Description
  • ICHI
  • CPT
  • ...
Procedure
  • Date
  • Description
  • Doses
  • ICHI
  • CPT
  • ...
Medicines
  • Date
  • Description
  • Doses
  • ATC/DDD
  • CPT
  • ...
Medical Records staff
Referrals handling, Billing, MSA withdrawing, ...


Doctor's interface standards:

Main challenge - don't busy doctor with typing, but provide entering most of analytic data.

Most of objects of patient's data and treatment process contain three level of information (at least):

Doctor can select valid objects from matching/suggested (selected and unselected will be kept).

Clinic settings allow defining "Selection required", "Select later" or "Optionally" options individually for each data source (MRW, ICD-10/11, ICHI, ATC/DDD, CPT, ...). In the first case doctor should select items in matching lists during record entering. In the second case doctor may open record later and make selections, or may delegate to other staff handling doctor's record later and making selections from matching lists. In the third case selection can be omited.





Clinic individual adjustments



Social Security Administration & Health Care Funds integration