E-Medical record

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.

  • Promotional film for electronic medical record

What is electronic medical record

The general electronic medical record includes

  1. Automated medical record (AMR)

  2. Computerized medical records (CMR)

  3. Electronic medical records (EMR)

  4. Electronic patient records (EPR))

  5. 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.

Smart Hospital Service –Electronic Medical Record Guide