CMUCH EMR system-increasing Efficiency, Productivity, and Service Quality Starting from the implementation date, the "medical records form" in the table below will be saved in the form of electronic medical records instead of printed for written reports. Related medical records inquiry, copying, and other operations are in line with the current regulations on medical records copying.
Cloud Medical Treatment
Cloud medical treatment is to use cloud computing technology to access information such as electronic medical records, numerical analysis, medical record storage, and remote medical care by the remote cloud computing center to establish a more convenient medical care system.
In line with Taiwan's policies on national health insurance and electronic medical records and under the guidance of the government, electronic medical records have become the basis of medical cloud formation, accomplishing the policy goal of holistic health care and reaching the broader health care market.
The Executive Yuan’s Department of Health will complete the construction of electronic medical records throughout Taiwan in 2014, gradually promoting the construction from large hospitals to clinics at all levels in Taiwan. Taiwan's nearly 15,000 clinics are a notable medical cloud market, as the number of the clinics is substantial in market size.
Insisting on innovation and leadership, the Hospital aims to make the greatest contributions to the process streamlining and content refinement of cloud medical applications.
Electronic Signatures, Attestation, and Authorship for Medical Record Documentation - Scope
| Title of Document | Implementation Date |
| All medical images and written reports (82 items) | Oct. 1, 2014 |
| All laboratory test reports and medical examination reports | Oct. 1, 2014 |
| Outpatient medical records form (including SOAP note) | Oct. 1, 2014 |
| Traditional Chinese medicine outpatient medical records | Oct. 1, 2014 |
| Discharge summary | Oct. 1, 2014 |
| Medication record (prescriptions) | Oct. 1, 2014 |
| Inpatient Nursing note | Oct. 1, 2014 |
| Nursing admission assessment sheet | Oct. 1, 2014 |
| Physical nursing health assessment and examination record | Oct. 1, 2014 |
| Inpatient order sheet | Oct. 1, 2014 |
| Consultation note | Oct. 1, 2014 |
| Consultation note on antibiotic prescribing | Oct. 1, 2014 |
| Inpatient transfer record | Oct. 1, 2014 |
| Emergency department Patient Record | Oct. 1, 2014 |
| Emergency department progress note | Oct. 1, 2014 |
| Emergency department order sheet | Oct. 1, 2014 |
| Emergency department nursing history | Oct. 1, 2014 |
| Emergency department nursing note | Oct. 1, 2014 |
| Emergency department medication note | Oct. 1, 2014 |
| Emergency department patient assessment and description records | Oct. 1, 2014 |
| Chronic pain assessment sheet | Oct. 1, 2014 |
| Pathology Reports | Oct. 1, 2014 |
| Cytology reports | Oct. 1, 2014 |
| Pap Smear Test Results | Oct. 1, 2014 |
| Inpatient pulmonary rehabilitation assessment report | Oct. 1, 2014 |
| Operation Note (including medical images) | Oct. 1, 2014 |
| Pre-op Assessment | Oct. 1, 2014 |
| Post-op Assessment | Oct. 1, 2014 |
| Pre-op and Post-op Assessment | Oct. 1, 2014 |
|
Pre-op and Post-op Assessment Pre-op and post-op assessment report for regional anesthetic surgery |
Oct. 1, 2014 |
| Traditional Chinese medicine progress note | Oct. 1, 2014 |
| Psychiatry Department Patient Medical Treatment Record | Oct. 1, 2014 |
| Admission note | Oct. 1, 2014 |
| Progress note | Oct. 1, 2014 |
| Patient treatment record for rehabilitation and physical therapy | Oct. 1, 2014 |
| Patient learning needs assessment and patient teaching record | Oct. 1, 2014 |
| Assessment in respiratory care- eligibility for ventilator liberation | Oct. 1, 2014 |
| Department of dentistry periodic oral health assessment and review checklist | Oct. 1, 2014 |
| Oral cancer and malignant disorders - personal habit records | Oct. 1, 2014 |
| Department of Dentistry Temporomandibular Joint Clinic assessment checklist | Oct. 1, 2014 |
| Insulin prescription &administration record | Oct. 1, 2014 |
| Hemodialysis/blood purification progress note | Oct. 1, 2014 |
| Inpatient hemodialysis nursing note | Oct. 1, 2014 |
| Outpatient Hemodialysis nursing note | Oct. 1, 2014 |
| Continuous Renal Replacement Therapy(CRRT) nursing note | Oct. 1, 2014 |
| SLEED-f treatment note | Oct. 1, 2014 |
| Double filtration plasmapheresis (DFPP) nursing note | Oct. 1, 2014 |
| Hemoperfusion (HP) nursing note | Oct. 1, 2014 |
| Plasma exchange（PE）nursing note | Oct. 1, 2014 |
| Total joint arthroplasty patient safety implementation plan | Oct. 1, 2014 |
| Outpatient injectable medicines prescription | Oct. 1, 2014 |
| Hemodialysis Room Restraint Assessment | Oct. 1, 2014 |
| Department of Psychiatry Close Observation Flow Sheet | Dec. 12, 2014 |
| Use of mechanical ventilation records | Dec. 12, 2014 |
| Peritoneal dialysis nursing assessment and description records | Dec. 1, 2014 |
| Nursing discharge instructions and checklist for newborns | Jan. 15, 2015 |
| Transfer of patient records and nursing note | Jan. 19, 2015 |
| Antepartum Record | Jan. 16, 2015 |
| Psycho-social Assessment | Feb. 1, 2015 |
| Physical Assessment and nursing note | Feb. 1, 2015 |
| Prepare for End-of-Life Care | Feb. 1, 2015 |
| Pain Assessment Guidance Records | Feb. 1, 2015 |
| Behavior Treatment Records-Establishment of Sense of Illness | Feb. 1, 2015 |
| Behavior Treatment Records-Event Participation | Feb. 1, 2015 |
| Behavior Treatment Records – Self-care | Feb. 1, 2015 |
| Behavior Treatment Records – Active Medication Intake | Feb. 1, 2015 |
| Physician's order (medical examination room) | Feb. 1, 2015 |
| Newborn Physical Examination Records | Mar. 16, 2015 |
| Chemotherapy injection Approval Form | Mar. 25, 2015 |
| Department of Psychology Discharge Preparation Planning & Group Meeting Records | Apr. 30, 2015 |
| Pre-Procedure Assessment | May 10, 2015 |
| Post-Procedure Note | May 10, 2015 |
| Quarterly Summary on hemodialysis | Jun. 15, 2015 |
| Single Ventricle Circulation or LCOS blood circulation | Jun. 15, 2015 |
| Examination Report | Jun. 15, 2015 |
| Acceptance Note | Jun. 15, 2015 |
| Clinic/Partial anesthetic surgery patient nursing assessment guidance form | Jun. 15, 2015 |
| Chemotherapy injection Physician order form | Jun. 15, 2015 |
| Post-delivery mother & infant nursing records | Jul. 1, 2015 |
| Pre-OP Assessment | Aug. 1, 2015 |
| Hospice care visiting form for other professional staff | Aug. 1, 2015 |
| Hospice care service content & records | Aug. 1, 2015 |
| Hospice care chart | Aug. 1, 2015 |
| Psychology Department Day-time Rehabilitation Center Activity Records | Aug. 1, 2015 |
| Psychology Department Day-time Ward Care Record Assessment | Aug. 1, 2015 |
| Psychology Department Day-time Rehabilitation Center Self- Management Training in Self-controlled drug usage | Aug. 1, 2015 |
| Psychology Department Day-time Occupational Therapy Assessment Records | Aug. 1, 2015 |
| Hemodialysis Unit – Patient Fall Assessment and Nursing Plan | Aug. 13, 2015 |
| Hemodialysis Pain Assessment | Aug. 13, 2015 |
| Hemodialysis Continuous Pain Assessment | Aug. 13, 2015 |
| Hemodialysis Health Education Assessment Chart | Aug. 13, 2015 |
| Monthly integration of Hemodialysis pharmaceutic drugs | Aug. 13, 2015 |
| Hemodialysis short-term physician order form | Aug. 13, 2015 |
| Hemodialysis Summary for Hospital Transfer | Aug. 13, 2015 |
| Pre-anesthetic assessment form | Aug. 15, 2015 |
| Mitigation and complication discussion meeting minutes | Sep. 1, 2015 |
| Type A certificate of diagnosis | Sep. 25, 2015 |
| Type B certificate of diagnosis | Sep. 25, 2015 |
| Type A certificate of diagnosis (for military service) | Sep. 25, 2015 |
| Medical Treatment Verification | Sep. 25, 2015 |
| Invasive treatment inspection chart | Sep. 25, 2015 |
| Hospitalization Integration Medicine Meeting Minutes | Sep. 30, 2015 |
| Pediatric Respiratory Treatment Records | Sep. 30, 2015 |
| Anesthetic Records | Oct. 1, 2015 |
| Sedation Records | Oct. 10, 2015 |
| Cardiac Catheterization Room Records | Oct. 15, 2015 |
| Psychology Department Day-time Rehabilitation (for physicians) | Oct. 15, 2015 |
| Psychological needs assessment and guidance record for palliative care patients | Oct. 15, 2015 |
| Hospice and palliative care patient medical records | Oct. 15, 2015 |
| Hospice and palliative care patient - Family Tree | Oct. 15, 2015 |
| Grading record of pelvic organ prolapse quantification system (POP-Q) for Endometriosis patients | Oct. 15, 2015 |
| Medical care guideline for discharge | Oct. 15, 2015 |
| Newborn birth certificate | Nov. 20, 2015 |
| Certificate of still birth for payment of maternity benefit in labor insurance | Nov. 20, 2015 |
| Anesthesia Recovery Nursing Records | Nov. 20, 2015 |
| Death certificate (Chinese) | Dec. 1, 2015 |
| Death certificate (English) | Dec. 1, 2015 |
| Surgery Nursing Records Sheet | Dec. 1, 2015 |
| Respiratory Abnormalities for newborns with severe conditions | Dec. 31, 2015 |
| Examination room assessment records (Upper digestive tract endoscope examination records [pediatrics]) | Jan. 27, 2016 |
| Nursing records before surgery | Jan. 4, 2016 |
| Surgery safety confirmation sheet | Jan. 4, 2016 |
| Pain Section Patient pain self-control records | Jan. 31, 2016 |
| Pediatrics ICU respiratory records | May 31, 2016 |
| Pediatrics ICU vital sign records | May 31, 2016 |
| Pediatrics ICU nursing record chart | Jun. 15, 2016 |
| Assessment sheet for termination of respirator – daily screening | Oct. 1, 2016 |
| Surgery consent form (including descriptions) | Mar. 1, 2017 |
| Anesthesia consent form (including descriptions) | Mar. 1, 2017 |
| entries | 210 |
Cloud Medical Treatment
The Hospital’s electronic medical records are made and managed in accordance with the Wei-Shu-I-Tzu No. 0980261732 document issued by the Department of Health, Executive Yuan on August 11, 2009.
The date and scope of the implementation of the Hospital's electronic medical records have all been reported to the Taichung Health Bureau for examination. In addition to the official document notice and online announcement, it is also published in obvious places at the Hospital; the same process will apply to the change or cessation of implementation.
Electronic medical records prepared and stored in electronic form by the Hospital pursuant to the regulations of the Department of Health are free from duplication in writing. The Hospital has no obligation to deliver written medical records except for special circumstances when it receives hospital accreditation or declares the payment of National Health Insurance by law.
Promotion Film on Electronic Medical Records : View
What Are Electronic Medical Records ?
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General electronic medical records include:
automated medical record，AMR
computerized medical records，CMR
electronic medical records，EMR
electronic patient records，EPR
electronic patient records，EPR
Medical records management concerns one of the most important systems in medical and administrative affairs in a hospital. Medical records are the important data in the hospital, recording all the progress of patients' disease. The detailed medical record is not only a guarantee for both doctors and patients, but also acts as a specific indicator of medical quality, demonstrating the comprehensive quality of medical practice and hospital management.
In October 2009, the Council for Economic Planning and Development approved the Department of Health’s addition of the Sub-project for the Acceleration of the Implementation of the Electronic Medical Record System in Medical Institutions to the Program for the Acceleration of the Implementation of Smart Medical Care. The project runs from 2010 until 2012, with a total of budget of NT$6 billion to achieve the goal of making electronic medical records available to people seeking medical advice in hospitals after three years.
Electronic medical records must have the legal force to supersede written medical records.
After the adoption of the Electronic Signatures Act in 2001, the competent authorities amended the Medical Care Act and with the authorization from the parent law, enacted the Regulations for the Preparation and Management of Electronic Medical Records by Medical Institutions so that the electronic medical records could be legally validated.
Electronic medical records must have a trusted and impartial third party (certification authority) to assist in verifying the physician's signature. Since July 2002, the Department of Health has started to establish a public key infrastructure (PKI)-based medical electronic authentication mechanism to ensure the operational security of electronic medical information, namely the setting up of the Healthcare Certification Authority (HCA).
The certificate IC card of the "medical institution" and "medical staff" issued by the HCA is used to identify the digital identity of medical staff and medical institutions.
Intelligent hospital service—electronic medical records promotion : View