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Physicians? Access and Notes

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The purpose of the module is to provide physicians associated with the Hospital, an easy mean of communicating with the ‘Hospital Information System’. Simultaneously the system should provide a facility for the Doctors to organize their notes and activities within the Hospital.

The following has been extracted from a recent RFP. I've included it here for your reference. It may prove useful for anyone preparing such a document.
Please feel free to comment on this list, and propose any items that you think should have been included in this list.

 

Physicians’ Access and Notes

Description
The purpose of the module is to provide physicians associated with the Hospital, an easy mean of communicating with the ‘Hospital Information System’. Simultaneously the system should provide a facility for the Doctors to organize their notes and activities within the Hospital.


>>> General
 
1   Provide online, easy to use system for physician to access patient demographic, clinical, order, and results information
2   Support physician access to hospital computer systems from physician offices using a terminal or compatible computers equipped with modems
3   Provide security confidentiality control features to prohibit physician from viewing and accessing data for other physician’s patients
4   Provide a facility to reduce the risk of transcription of notes to an erroneous patient chart
5   Support the use of hand held devices
6   Support the concept of pick lists

>>> Physician Access
 
7   Support physician’s access to hospital computer systems from terminals or PC’s within hospital
8   Provide security access control features that validate physician ID before allowing access to patient data
9   Provide online help screens for all physician’s access system funcions
10   Provide ability to initiate system functions by selecting menu options with keyboard or mouse pointing device
11   Provide census inquiry screen showing name, nurse, station, room, age, gender, and diagnosis for patients of physician who is logged on
12   Provide online access to hospitals’ patient appointment scheduling system via physician’s access system
13   Provide electronic mail (email) functions for physicians to exchange message with other physicians or hospital staff
14   Support online entry and cancellation of lab orders to hospital’s lab information system
15   Support online entry and cancellation of imaging orders to hospital’s imaging order processing system
16   Support online entry and cancellation of RT orders to hospital’s respiratory therapy order processing system
17   Support online entry and cancellation of cardiology ( ex: EKG) orders to hospital’s cardiology order processing system
18   Support online entry and cancellation of medication orders to hospital’s pharmacy system
19   Allow menu-bypass or speed entry codes of orders for experienced users who do not need menu assistance
20   Allow physician to page forward and backward in order entry screens , if multiple screens
21   Provide electronic signature ID function for physician to electronically record approval and entry of orders
22   Ability to keep track of medical equipment connection time for inpatients

>>> Physicians ( Clinicians ) Notes and Activities
 
23   Ability to display and review the list of activities for any defined resource in the Hospital
24   Ability to filter the activities by resource type, resource, activity type, or a range of dates
25   Ability to view past and future dates ( possible with handy electronic calendar )
26   Color coded entries to identify the currently selected activity, booked and free time slots, and scheduled conflicts
27   Ability to send messages to physicians and other care providers ( messages may or may not be related to specific results or patient documentation , and may not be part of the electronic patient record )
28   Allow the filing of scanned documents as part of the patient file
29   Provide facility to assign clinical codes to a patient file
30   Allow the users to employ any diagnostic coding types ( ex: ICD10, Read, etc.. )
31   Allow the assigning of ‘local aliases’ to diagnosis
32   Allow the assigning of codes to a patient file by :- A clinician on a ward
33   Allow the assigning of codes to a patient file by :- A clinician in a clinic
34   Allow the assigning of codes to a patient file by :- A patient administrator in medical records
35   Allow the assigning of codes to a patient file by :- Allow the coding of planned investigations and procedures for patient referral yet to attend
36   Allow the assigning of codes to a patient file by :- Allow the assigning of provisional diagnosis codes subject to confirmation
37   Allow the assigning of codes to a patient file by :- Allow historical diagnosis information to be made available to the user at the time of assigning the diagnosis
38   Permit the deletion of diagnosis data entered erroneously
39   Prevent deletions, allowing instead , the incorrect diagnosis to be shown as ‘not relevant’ but to still appear on the screen
40   Ability to record the following information:- Clinician making the diagnosis
41   Ability to record the following information:- User entering the diagnosis
42   Ability to record the following information:- Date and time diagnosis is entered

>>> Query
 
43   Allow the search for diagnostic code by code, procedure name and investigation by code and name
44   Provide online patient inquiry function showing demographic, guarantor and insurance data for patients of physician who is logged on
45   Provide online patient inquiry function showing name and phone of family and emergency contacts for patients of physician who is logged on
46   Provide online inquiry into medical history for patients of physician who is logged on
47   Display patient’s demographic and diagnosis data on all order entry screens
48   Support online display of physicians patient current lab orders
49   Support online display of physician’s patient current imaging orders
50   Support online display of physician’s patient current respiratory therapy
51   Support online display of physician’s patient current cardiology orders
52   Support online display of physician’s patient current medication orders
53   Support online graphical display of physician’s patient lab test results for trends, etc..
54   Support ability to display graphical, digitilized diagnostic images from hospital digital imaging storage and retrieval system

>>> Reports
 
55   Print census showing name, nurse station, room, age, gender and diagnosis for patients of physician who is logged on
56   Provide ability to print physician’s patient current lab orders
57   Provide ability to print physician’s patient current imaging orders
58   Provide ability to print physician’s patient current respiratory therapy
59   Provide ability to print physician’s patient current cardiology orders
60   Provide ability to print physician’s patient current medication orders
61   Provide ability to print physician’s patient lab test results
62   Provide audit trail function that logs each access to patient data
63   Print audit trail report by patient that lists all accesses to patient data


Last Updated ( Tuesday, 28 October 2008 01:42 )  

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