im about to design an electronic medical record that can be used in different medical specialties. is there some medical form that i can refer to? i plan to implement it in a clinical setting
2007-08-21 20:10:05 · 3 answers · asked by andy 2 in Science & Mathematics ➔ Medicine
Well, nothing really that I heard of such thing as generic medical record. Usually electronic medical records are designed separately per different specialties.
Anyway, you actually have a great idea. I believe that there are many health care establishments that deal with mixed up cases covering various specialties. Your designed plan would fit for use in facilities covering all sorts of cases.
You may design a simple but generalized format that will be applicable to every case. It will be a bit difficult as the different specialties got particular differences but be creative to find some tricks to include important aspects in every specialty while trying to make it appear as a generalized record.
The different forms used in the written patient charts would be your best references. Try to be familiar with the following forms:
>> patient's identification information
>> the patient's health history
>> patient's medical examination findings
>> Treatment and management Sheets.
>>all the forms you will see in the patient's record.
Checking out those forms in a nearby hospital would be a wise choice.
Oh well, it would be quite a task for you to do while I am not of really great help but one thing I am sure of is that your idea is brilliant. Good luck!
2007-08-21 21:04:58 · answer #1 · answered by ♥ lani s 7 · 0⤊ 0⤋
Demographics, history and physical, progress notes, and doctors orders can be fairly generic forms. Why don't you get copies of a few blank charts from different settings and see what you can extrapolate from them?
2007-08-25 22:02:10 · answer #2 · answered by javadic 5 · 0⤊ 0⤋
A patient's family history
2007-08-22 06:21:45 · answer #3 · answered by Pahd 4 · 0⤊ 0⤋