2024 Public Hospital Performance Assessment in Progress, Contract Lock Electronic Signature Helps with Electronic Medical Record Rating

The performance evaluation of public hospitals in 2024 is currently underway, and the latest "Operation Manual for Performance Evaluation of National Second level Public Hospitals (2024 Edition)" and "Operation Manual for Performance Evaluation of National Third level Public Hospitals (2024 Edition)" issued by the National Health Commission will; The analysis of the functional level of electronic medical record applications should be gradually improved; Listed as newly added assessment indicators . The application of electronic medical records is an important indicator of the digitalization level of hospitals, and it is also one of the performance evaluation indicators of public hospitals. According to the "Management Measures for Grading Evaluation of Application Level of Electronic Medical Record System (Trial) and Evaluation Standards (Trial)", the evaluation of electronic medical records is divided into nine levels and 39 scoring items from 0 to 8. Among them, there are a total of 6 items and 16 evaluation contents related to identity authentication and electronic signatures, and the higher the application level, the more requirements for electronic signature application. (Content sourced from the "Management Measures for Grading and Evaluating the Application Level of Electronic Medical Record Systems (Trial) and Evaluation Standards (Trial)") Currently, the construction of electronic medical records at level 4 in public hospitals has been basically completed, and the rating has entered level 5 or higher. Electronic signatures will be changed from; Bonus Points” Gradually becoming; Basic Item” Rating is becoming increasingly important. As a leading electronic signature and seal control manufacturer in the industry, Contract Lock has rich experience in the field of electronic signatures in medical institutions. It can help large hospitals build a unified electronic signature and seal control platform that supports integration with various hospital digital software. Implement real name authentication login business system for medical staff, online production and use of electronic signatures for doctors and patients, and one click writing of medical record file templates to promote“ Outpatient diagnosis and prescription in hospitals; Medical technology examination and laboratory testing, pharmacy medication retrieval, hospitalization registration, surgical treatment, nursing, and discharge, etc; Electronic signature of medical records for all medical scenarios.

Medical record electronic signature scene covering the entire process of hospital medical services

Meeting the electronic signature needs of medical staff in various departments of the hospital 01 Outpatient

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includes: electronic prescriptions, medical orders, examination application forms, diagnosis certificates, sick leave certificates, patient medical records, etc.

· Electronic prescriptions are equipped with hospital HIS information management system or Internet medical platform to provide outpatient doctors with electronic signature services, fill in prescription information online, automatically add signatures after confirmation, and generate electronic prescriptions by using point electronic templates with one click, locking data, realizing prescription encryption and flow without tampering. Ensure that the prescription generation and circulation process is recorded and traceable.

· Medical Order Form

The medical order form is filled out, changed, and invalidated by the attending physician, and executed by the nurse. The entire operation process records the real treatment plan and treatment process of each patient, and it is necessary to ensure the authenticity and credibility of each data. Through the application of electronic signature, every operation of each medical order data can be automatically bound to the real identity of the operator, ensuring that the individual's operation:

Doctor

adds, changes or cancels a medical order data in the HIS system, Nurse submits medical order execution data, and the system automatically verifies the real intention and adds an electronic signature.

Save the trouble of frequent manual signatures, automatically sign after medical confirmation, and help generate electronic medical orders for each patient according to file format requirements. · Patient electronic medical record Outpatient doctors record the patient's condition, diagnosis, and treatment information in the EMR electronic medical record system. During the submission confirmation process, they retrieve the electronic signature reserved in the contract lock system to complete the signature, generate the patient's electronic medical record, and automatically archive and save it. · Examination Application Form

Outpatient doctors create examination applications for patients in the HIS system, confirm submission, and synchronously add the doctor's electronic signature information without printing paper application forms. Examination application information is automatically shared, improving data flow efficiency.

· Diagnosis/sick leave certificate

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03 Hospitalization

Includes: Hospitalization certificate, hospitalization record, medical record homepage, hospitalization medical order form, hospitalization medical record, discharge certificate, etc.

· The country requires hospitals at all levels to record patients' basic information, hospitalization medical and diagnostic conditions, as well as hospitalization expenses and other information on the first page of their medical records. This type of material involves a wide range of medical data and often requires signatures from multiple parties such as attending physicians, resident physicians, chief physicians, department heads, and responsible nurses to be effective and archived. Through the application of electronic signatures, the EMR electronic medical record system can provide data signature and true intention verification services for various medical staff participating in treatment. From generation, modification to archiving and signing for inpatient medical records, the entire process is online and the responsible person moves and signs one by one, making the entire process paperless.

· The admission record sheet records the patient's condition and basic diagnosis, and generally requires signatures from both the doctor and the patient themselves. The application of electronic signatures can not only use facial recognition technology to ensure the patient's signature, but also replace paper document signing with mobile SMS signing, improve signing efficiency, and ensure the authenticity and credibility of recorded information.

04 Surgery

includes:

Surgical application form, informed consent form, etc.

Surgical application form, informed consent form, and other documents that require joint signature by patients or family members and the hospital.

The HIS hospital information system, handwritten screen device, and electronic signature system can be integrated

. Doctors fill in surgical information in the business system and submit the signing process. Patients use the handwritten screen device to complete identity authentication, sign the application form or consent form online, and the hospital automatically stamps and quickly completes the signing. 05 Nursing

includes: Nursing record sheets, nursing documents, nursing evaluation forms, etc. Patient nursing records in the inpatient department need to be filled out and signed by nurses in real time every day. Through the application of electronic signatures, nurses can log in to the HIS system to record nursing data after nursing every day. After confirmation, the system automatically retrieves the electronic signature reserved by the nurse in the contract lock system to complete the signature, without the need for paper documents, with full process tamper proof and traceable, ensuring the credibility of nursing data.

06 Pharmacy

Includes: Pharmacist identity authentication, pharmacist review and signature, etc.

Pharmacy review and dispensing doctor real name authentication login to HIS system, online approval of prescription information, confirmation of dispensing, system automatically adds the doctor's electronic signature to complete the signature, and there are data records throughout the review and dispensing process, which can be accessed at any time. In addition, the contract lock can also provide identity authentication support for various business systems of the hospital, ensuring that medical staff log in themselves and making all operations in the system non repudiation and authentic. According to the electronic medical record rating requirements of public hospitals, various business systems of hospitals should have identity authentication functions. Contract Lock has cooperated with authoritative CA institutions across the country to provide user real name authentication and genuine intention verification services through various business systems integrated into hospitals, ensuring that all operations such as system login, process initiation, approval, signing, and querying are carried out by oneself, ensuring data security and trustworthy operations.

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Summary

As a key industry for national digital construction and information and innovation construction, the medical industry has explored the application of electronic signatures more deeply and diversified scene construction. The contract lock electronic signature and seal control platform integrates the requirements of the "Electronic Medical Record Application Management Specification (Trial)" and the "Electronic Signature Law" to meet the needs of the hospital industry; Data signature, electronic template, signature authorization, trusted timestamp, information and innovation adaptation and transformation services, etc; We have helped numerous second - and third tier public hospitals in various provinces and cities expand their medical electronic signature scenarios, assisting in the continuous development of hospital electronic medical record applications to a higher level and accelerating the digital construction of medical information and innovation!