Automation of the formation of medical examinations for electronic medical history in medical information systems

Abstract

This article examines the documentation of medical records on electronic media and suggests the formalization and documentation of medical data in the medical information system for maintaining an electronic medical history. The basic technologies and interface for documenting medical records, the formation of electronic templates for standardization, the design of electronic doctors’ examinations and the terminology used are provided. A software solution for the formation of medical records, the structure of the descriptive part of the prepared templates for medical examinations, and the use of special software allowing the procurement of terms in a six level structure are provided. The use of this medical records technology can improve efficiency, standardize the examinations and terminology used, and structure the medical information generated during the doctor’s examination to produce a detailed scientific analysis of the many signs of various pathologies for creating a system to support diagnostic decision making.