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A Web-based Platform for Implementing Clinical Notes A production of clinical medical records of web-basedplatform

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A production of clinical medical records of web-based platform

A Web-based Platform for Implementing Clinical Notes

Chin-Jung Chen a, * Chia-Hsien Wen a, b, Yeda Cheng c, Chen Qiwen d Chin-Jung Chen a, Chia-Hsien Wen a, b, Dah-Cherng Yeh c, Chiwen Chen d

a Taichung Veterans General Hospital Information Department, b University of Information Science and Engineering, East China Sea

c Taichung Veterans General Hospital, General Surgery, d Ju Ren Technology Co., Ltd.

a Computer & Communication Center, Taichung Veterans General Hospital

b Department of Computer Science & Information Engineering, Tunghai University

c Division of General Surgery, Department of Surgery, Taichung Veterans General Hospital

d INQGEN Technology Co., Ltd.

* E-mail: chwen@vghtc.gov.tw Summary

For the implementation of electronic medical records, Taichung Veterans General Hospital developed a clinical medical records produced web-based platform. This

platform will be the clinical records of each style and content into two parts, and provide the style designer, content editor, and record the three generators and other functions. The design of clinical units available style home design style necessary clinical records; physicians by

content editor input medical records; record generator Ke Yi style to the content of the information input into the clinical record of the article type for online viewing or printing .

Entered clinical information to XML format, stored in a

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database, clinical staff can provide in the future of medical research. Ben Wang-based platform for the development of the clinical use of medical records, not to be involved in software development personnel, can save a lot of the development of human, but also greatly simplifies and reduces clinical medical records computerized process.

The clinical records has been completed a total of 144 kinds of styles, including all hospital medical records of each

clinical section of the summary of operation records, medical records and discharge summaries.

Keywords: Clinical medical records, electronic medical records, web-based platform

Abstract

Taichung Veterans General Hospital (TCVGH) has developed a web-based platform for implementing clinical notes as a pilot system to promote electronic patient

records. Each clinical note is partitioned into a template and a set of data contents.

The platform provides three functions, named template designer, content editor, and note generator, for physicians to implement patients' clinical notes. The template designer is used to set up the format, called template, of a clinical note. A physician may enter and edit contents of a clinical note by the content editor under its template.

According to the template and entered contents, the note generator generates a textual note for review and print. Using this web-based platform, a hospital may simplify the process in implementing her tremendous clinical notes without devoting any application designer. There are 144 templates of admission notes, operation notes, and discharge notes in TCVGH now.

Keywords: Clinical note, Electronic patient record, web-based platform

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