Generating Standardized Clinical Documents for Medical Information Exchanges

摘要

The author mentions that in order to facilitate the exchange of medical information, Taiwan's Department of Health supported a project to standardize electronic medical records. Part of this project involved developing a system that automatically generates samples for the 108 different types of standard documents. The paper discusses the efforts to create a comprehensive specification system to help hospital staffs create EMRs that conform to the HL7 CDA. The guidelines comprise online documents and formats, categorized according to the various paper forms used in different hospitals. For ease of use, the Standardization Clinical Document Generation System was also developed. The system generates sample documents automatically, thereby maintaining consistency and reducing human errors.