부산대학교 도서관

Purpose: In order to promote the basic construction of smart medical care at our hospital and the structurization and electronization (the latter can also be called electronicization, document digitalization, or computerization) of future consult data, a structured form (including the function of inserting pictures) will be used to rebuild the integrated version of the consult system to implement the structuring of medical records, import electronic medical records to realize electronic consult data, and reduce the cost of documentation. Method: 1. Using C# as the principle language, along with developing tools provided by Microsoft Visual Studio and the MVC framework of Web (Model-View-Controller) to proceed the development; as the mentioned two added together, the resulted program structure became more intuitive, the system management more convenient, which is a plus for group developments. 2. Data integration and structure reorganization: The structure of the new version of the consult system will be established by the master/slave data table. The main data table records the relevant information of the consult application, including the patient information, name of the applicant, time of application, responder, reply time, the status of the consult, etc., also the subordinate data table records of the details of the consult's application content, reply content, and timing modification if any 3. Using interface adjustment and design: The new version of the consult system will be designed on the Web platform, which can be operated independently by the browser, and a number of column collapsing functions have been added, so that the user's editing area can be maximized and improved. The display of method list allows the user to quickly identify the information of the currently selected patient, and simultaneously display the name and contact information of the attending physician, resident physician, and specialist nurse of the patient, and import the form system and insert the picture module, and assist the clinical department to establish a common form format. Results: 1. Reducing the number of paper-based medical records that are printed and replied to: When the electronic medical record has not been imported into the consult system, the paper-based medical records still need to be printed and stored with the patient's medical records. On average, more than 50,000 paper-based medical records need to be printed in a year. Therefore, after importing the electronic medical record, the number of times of printing can be reduced, the cost of printing paper and the amount of carbon emissions generated during printing can be saved. 2. Increasing the integrity of the content of the consult: The new version of the consult system provides various tools such as pictures and forms to help doctors increase the integrity of the content when writing the reply. In the future, the doctor's phrase and the examination and lab data will be added. 3. The system automatically sent consult according to the patient's condition and relevant clinical data: In response to the diverse conditions of the patient, if the conditions for a specific condition were met, the system would actively send the consult to the relevant clinical unit, and it could also interface with other systems. At the discretion of the physician, a consult application could be initiated immediately. Conclusion: Through the import of the form and the function of inserting pictures, the physician who is in the consult can clearly know what materials to prepare when applying for a consult, which options to check, and clearly express the reason for the consult. Further, pictures can be used to illustrate the condition to further improve the integrity of the content. On the contrary, the consulting physician can also use pictures to reply after completing the consultation and attach the treatment or suggestion, which makes the content of the reply more complete, and also implements the structuring and electronization of medical records.