Research On The Medical Record Digitization

Medical records are valuable information for the medical profession, which are objective, complete, continuous records of a large number of treatment information, medication records, laboratory data,and it played important roles in teaching, research, management, forensic and other aspects. In order to convenient remote medical treatment, multi-hospital treatment and Medicare evidence, we must digitize medical records without delay.However, the digitization of medical records in China is still in early stage, and there are no uniform standards of digital processing and describing metadata now. In view of this, this paper focuses on the digital methods, processes, digitized storage, metadata description of medical records and discusses them in depth. Furthermore, learning from foreign mature medical informatics standards and metadata standards, and basing on the local hospital actual needs proposes a set of the digital medical record descriptive metadata. The paper aims at promoting the digitization of medical records into a system of standardized criteria to make medical records to achieve true digital, network, and give full play to their intelligence value.The paper firstly analysises the study background and research significance of the medical records digitization, and summarizes achievements and experience of digital medical records and the relevant medical informatics standards. The second chapter illustrates the concept and content of medical records, and summed up its characteristics and types as well. The following three chapters discuss specific work of medical records digitization in detail. The third chapter focuses on digital methods and workflows, summarizes the present medical record archiving methods and digital methods of processing through literature research and interviews examine. The forth chapter studies storage technology of medical records and the method of storage after digitations. In the chapter five, the paper focuses on domestic and international medical informatics standards and metadata standards. On the base of abundant investigation and analysis, the paper proposes the medical records descriptive metadata set.