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E-Medical record
CMUH EMR system – increasing Efficiency, Productivity, and Service Quality
The following “Medical Record Form” in the following table will be stored via electronic medical record since the day of implementation and additional printed report will not be provided.
The query and duplication process for relevant medical record will be processed in accordance with the existing regulations governing the printing and duplication of medical record.
Cloud Medical Care
Cloud medical care applies cloud computing technology to access shared data such as electronic medical record, data analysis, diagnosis records storage and remote medical care from the remote cloud computing center to establish a more convenient medical insurance and health system.
In cooperation the policies regarding Taiwan national health insurance and electronic medical record, Taiwan Medical Cloud has incorporated electronic medical record as the foundation of medical cloud form under government guidance, thereby accomplishing the policy objectives in holistic health care with more access to the broader health care market.
The Ministry of Health and Welfare, Executive Yuan, completed the establishment of electronic medical record all over Taiwan in 2014, promoting from large hospitals to eventually clinics at all levels in Taiwan. There are nearly 15,000 clinics in Taiwan that draw attention to the medical cloud market since this number of clinics is a considerable market size.
CMUH upholds to innovation and leadership by simplifying the process and content of cloud medical application with the optimal contribution.
Scope of Implementing Electronic Medical Record Signature Process
| Date of Implementation and Activation | Description | |
|---|---|---|
| Radiology Department Medical Imaging Report | May 22, 2010 | 48 pages |
| Test Report | May 20, 2010 | |
| Release of Medical Information | August 10, 2010 | |
| Outpatient Medical Records | August 10, 2010 | Prescription |
| Medication Administration Note | July 5, 2011 | |
| Inpatient Nursing Note | September 1, 2011 | |
| Chinese Medicine Department Clinic Medical Note | September 5, 2011 | |
| Outpatient Medical Note | November 15, 2011 | Including SOAP |
| Admission Nursing Assessment | January 16, 2012 | |
| Physical Nursing Assessment | January 16, 2012 | |
| Medical Advice and Medical Order for Hospitalization | August 15, 2012 | |
| Consultation Response Note | December 17, 2012 | |
| Antibiotic Use Review Note | December 17, 2012 | |
| Department (Bed) Transfer Medical Record | December 17, 2012 | |
| Emergency Nursing Record | February 8, 2013 | |
| Emergency Nursing Medical Record | February 8, 2013 | |
| Pain Continuation Assessment Note | April 1, 2013 | |
| Pathological Examination Report for Pathology Department | April 9, 2013 | |
| Cytology Test Report | April 9, 2013 | |
| Cervical Biopsy Report for Women | April 9, 2013 | |
| Inpatient Respiratory Function Improvement and Treatment Assessment Note | May 1, 2013 | |
| Operation Note | October 1, 2013 | Image files included |
| Emergency Administration Note | December 9, 2013 | |
| Emergency Health Education Assessment and Instruction Note | December 9, 2013 | |
| Pre-op Assessment | December 9, 2013 | |
| Post-op Assessment | December 9, 2013 | |
| Local Anesthetic Surgical Pre-op and Post-op Assessment | December 9, 2013 | |
| Chinese Medicine Progress Note | December 25, 2013 | |
| Psychiatry Department Treatment Note | December 25, 2013 | |
| Admission Medical Record | February 10, 2014 | |
| Progress Note | February 10, 2014 | |
| LABOR NOTE | February 10, 2014 | |
| Problem List | February 17, 2014 | |
| Emergency Medical Record | April 7, 2014 | |
| Emergency Progress Note | April 7, 2014 | |
| Emergency Medical Advice Note | April 7, 2014 | |
| Rehabilitation and Treatment Note | April 28, 2014 | |
| Nutrition Assessment Follow-up Note | April 28, 2014 | |
| Health Education Assessment and Instruction Note | April 28, 2014 | |
| Respiratory Treatment Assessment – Ventilator Weaning Program | May 1, 2014 | |
| Dentistry Department Oral Care Routine Examination Note | May 1, 2014 | |
| Oral Cavity Cancer and Precancerous Lesions Personal Habit Record Note | May 1, 2014 | |
| Dentistry Department Temporomandibular Joint Outpatient Assessment Note | May 1, 2014 | |
| Insulin Administration Note | June 1, 2014 | |
| Hemodialysis/ Blood Purification Progress Note | June 13, 2014 | |
| Inpatient Hemodialysis Nursing Note | June 16, 2014 | |
| Outpatient Hemodialysis Nursing Note | June 16, 2014 | |
| CRRT Nursing Checklist | June 16, 2014 | |
| SLEED-f Nursing Treatment Note | June 16, 2014 | |
| Double Filtration Plasmapheresis Treatment Nursing Note (DFPP) | June 16, 2014 | |
| Hemoperfusion Treatment Nursing Note (HP) | June 16, 2014 | |
| Plasma Exchange Treatment Nursing Note | June 16, 2014 | |
| Joint Replacement Patient Safety Measures | July 21, 2014 | |
| Outpatient Injection Note | August 1, 2014 | |
| Hemodialysis Room Admission Evaluation | October 1, 2014 | |
| Postnatal Discharge Preparation Nursing Guide Note | November 17, 2014 | |
| Peritoneal Dialysis Nursing Evaluation Note | December 1, 2014 | |
| Department of Psychiatry Intense Observation Note | December 12, 2014 | |
| Ventilator Recording | December 12, 2014 | |
| Newborn Discharge Preparation Nursing Guide Note | January 15, 2015 | |
| Newborn Birth Note | January 16, 2015 | |
| Bed Transfer Care Summary Note | January 19, 2015 | |
| Psychological Social Assessment | February 1, 2015 | |
| Physical Assessment and Nursing Records | February 1, 2015 | |
| Hospice Preparation Memos | February 1, 2015 | |
| Pain Assessment and Counseling Records | February 1, 2015 | |
| Behavioral Treatment Note – Establishing Intellectual Insight | February 1, 2015 | |
| Behavioral Treatment Note – Activity Involvement | February 1, 2015 | |
| Behavioral Treatment Note- Self Care | February 1, 2015 | |
| Behavioral Treatment Note – Voluntary Medication | February 1, 2015 | |
| Medical Order (Examination Room) | February 1, 2015 | |
| Newborn Physical Examination Note | March 16, 2015 | |
| Chemical Treatment Injection Medical Order Approval Form | March 25, 2015 | |
| Psychiatry Discharge Preparation Plan and Team Meeting Minutes | April 30, 2015 | |
| Pre- Procedure Assessment | May 10, 2015 | |
| Post-Procedure Note | May 10, 2015 | |
| Department of Radiology Job Description | June 1, 2015 | |
| Hemodialysis Quarterly Summary | June 15, 2015 | |
| Single Ventricle Circulation or Low Cardiac Output Syndrome (LCOS) Hemodynamics Assessment Calculation Form | June 15, 2015 | |
| Examination Report | June 15, 2015 | (written report, excluding figures, total 34 pages) |
| Acceptance Note | June 15, 2015 | |
| Outpatient /Local Anesthetic Surgical Patient Nursing Assessment Guide | June 15, 2015 | |
| Labor Pre-Assessment | June 15, 2015 | |
| Chemotherapy Injection Medical Order | June 15, 2015 | |
| Postpartum Mother-Baby Nursing Note | July 1, 2015 | |
| Cardiac catheterization Pre-OP Assessment | August 1, 2015 | |
| Hospice Co-Care with Other Professional Visit Form | August 1, 2015 | |
| Hospice Co-Care Service Content and Recording | August 1, 2015 | |
| Hospice Co-Care Form | August 1, 2015 | |
| Psychiatry Department Daytime Rehabilitation Center Activity Records | August 1, 2015 | |
| Psychiatry Department Daytime Ward Nursing Records Assessment Form | August 1, 2015 | |
| Psychiatry Department Daytime Rehabilitation Automated Drug Management Training | August 1, 2015 | |
| Psychiatry Department Daytime Ward Occupational Treatment Evaluation Records | August 1, 2015 | |
| Blood Hemodialysis Room Patient Fall Assessment and Nursing Plan | August 13, 2015 | |
| Hemodialysis Pain Assessment | August 13, 2015 | |
| Hemodialysis Pain Continuation Assessment | August 13, 2015 | |
| Hemodialysis Health Education Assessment | August 13, 2015 | |
| Hemodialysis Medicine and Medical Order Monthly Consolidation | August 13, 2015 | |
| Hemodialysis Short-Term Medical Order | August 13, 2015 | |
| Hemodialysis Hospital Transfer Summary | August 13, 2015 | |
| Anesthesia Pre-Assessment Form | August 15, 2015 | |
| Palliative Team Case Discussion Meeting and Complications Discussion Meeting Minutes | September 1, 2015 | |
| Class A Certificate of Diagnosis | September 25, 2015 | |
| Class B Certificate of Diagnosis | September 25, 2015 | |
| Certificate of Diagnosis for Military Service | September 25, 2015 | |
| Medical Certificate | September 25, 2015 | |
| Invasive Treatment Checklist Form | September 25, 2015 | |
| Admission Holistic Integrated Medical Care Meeting Minutes | September 30, 2015 | |
| Pediatric Reparation Treatment Notes | September 30, 2015 | |
| Anesthesia Note | October 1, 2015 | |
| Sedation Note | October 10, 2015 | |
| Cardiac Catheterization Job Description | October 15, 2015 | |
| Psychiatry Department Daytime Rehabilitation Center Activity Records (for use by physicians) | October 15, 2015 | |
| Hospice and Palliative Care Spiritual Needs Assessment and Counseling Records | October 15, 2015 | |
| Hospice Care Profile | October 15, 2015 | |
| Genogram of Hospice Care Patients | October 15, 2015 | |
| Endometriosis Stage Recording | October 15, 2015 | |
| Discharge Preparation Service Medical Record | October 15, 2015 | |
| Certificate of Birth | November 20, 2015 | |
| Certificate of Stillbirth | November 20, 2015 | |
| Postnatal Nursing Guide Note | November 20, 2015 | |
| Anesthesia Recovery Care Note | November 20, 2015 | |
| Inspection Room Assessment Note | November 20, 2015 January 1, 2016 |
|
| Certificate of Death | December 1, 2015 | |
| Certification of Death in English | December 1, 2015 | |
| Surgery Nursing Note | December 1, 2015 | |
| Newborn Moderate / Severe Ward Respiration Anomaly Note | December 31, 2015 | |
| Security Safety Conformation Note | January 4, 2016 | |
| Security Safety Conformation Note | January 4, 2016 | |
| Department of Pain Patient-Self-Control and Analgesia Note | January 31, 2016 | |
| Home Care Doctor Visit Medical Records | January 31, 2016 | |
| Pediatric Intensive Care Unit Respiratory ICU Note | May 31, 2016 | |
| Pediatric Intensive Care Unite Vital Signs Note | May 31, 2016 | |
| Pediatric Intensive Care Unit Nursing Record and Progress Note | June 15, 2016 | |
| Amniocentesis Note | August 1, 2016 | |
| Ventilation Weaning Assessment Note – Daily Screening Assessment Note | October 1, 2016 | |
| Surgery Informed Consent (instruction included) | March 1, 2017 | |
| Anesthesia Informed Consent (instruction included) | March 1, 2017 |
Description of CMUH Electronic Medical Record
The production and management of CMUH electronic medical record are implemented in accordance with the letter Yi-Ci No. 0980261732 dated August 11, 2009, issued by the Executive Yuan Department of Health.
The date and scope of implementation for the CMUCH medical record have been reported to the Taichung City Department of Public Health for review. Apart from issuing official document for notice, CMUH also announces online and discloses on visible sites in CMUH. The same procedures shall apply to change or suspension of implementation.
CMUH prepares and stores electronic medical records via electronic documents required by the Department of Health and shall be exempt for reproduction via written form. Except for special circumstances, CMUH may not be held accountable for delivering medical records in written form when accepting hospital accreditation or filing for benefits from national health insurance.
What is electronic medical record
The general electronic medical record includes
-
Automated medical record (AMR)
-
Computerized medical records (CMR)
-
Electronic medical records (EMR)
-
Electronic patient records (EPR))
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Electronic health record (HER)
Medical management is one of the key systems for the medical affairs and administration of hospitals. Medical records are important data of hospitals which record all the illness development and process of patients. Medical records with detailed in content not only protect the hospitals and patients but also serve as the specific indicators of medical quality, presenting a comprehensive quality between physician practice and hospital management.
Council for Economic Planning And Development passed the new “Accelerate the Establishment of EMR System in Medical Institutions” sub-program proposed by the Department of Health added to the “Accelerate the Implementation of Smart Medical Care Program” in October 2009. The program schedule lasted between 2010 and 2012 with a total of NTD6 billion in funding and the objective aiming at provide electronic medical records for all public seeking for medical help at the hospital in three years.
Electronic medical records must have the legal effect to replace medical records in writing.
After the Electronic Signatures Act was passed in 2001, the competent authority has revised the Medical Care Act and formulated the regulations governing the electronic medical record production and management in medical institutions in accordance with the authorization of parental law, consequently providing legitimate reference for electronic medical records.
Electronic medical records require credible and impartial third party (certification authority) to assist with the validation of physician signature. The Department of Health started establishing a Public Key Infrastructure (PKI) based medical electronic certification mechanism in July, 2002 to assure the security of medical electronic process, and namely the establishment of Healthcare Certification Authority (HCA).
The “Medical Institution” and “Medical Staff” certification IC card issued by the Healthcare Authority are used to identifying the digital identity of medical staff and medical institutions.
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