Technologies for electronic generation of medical records in medical information systems

Abstract

The article examines the documentation of medical records on electronic media, suggests the formalization and documentation of medical data in the “ExterNET” medical information system for maintaining an electronic medical history. The basic technologies and interface for documenting medical records, the formation of electronic templates for standardization, the design of electronic examinations of the doctor and the terminology used are given. In order to formalize and document medical records, “electronic templates for medical records” have been proposed; the template structure is composed in a strictly defined sequence corresponding to the medical stages of the document, in which all the information entered is formalized and structured as much as possible. A software solution for the formation of medical records, the structure of the descriptive part of the prepared templates for medical examinations, the use of special software allowing the procurement of terms in a six-level order are given. The use of such a technology of medical record provides a gain in time, standardization of the examination, the terminology used, structuring the medical information generated during the examination of the doctor for a detailed scientific analysis of the many signs of various pathologies to create a system to support diagnostic decision making.