Introduction. Introduction Patient Medical Records

The solution "1C-Rarus: Ambulatory, edition 1.0" accumulates methodological solutions and accumulated experience of the 1C-Rarus company in the automation market of medical organizations, such as the Stem Cell Bank "CryoCenter", LLC "EL-CLINIC", Therapeutic Cosmetology Clinic " UNASKIN."

Description of functionality

The system is designed to automate the following areas:

Registry

• Registration of new and search for previously registered patients
• Maintaining records of patients by area
• Specifying an insurance program with the ability to control
• Making appointments and registering doctors' home calls
• Maintaining work schedules for medical personnel
• Preparation of medical documentation: medical record, statistical certificate, etc.
• Planning medical appointments
• Patient survey
• Personal data of employees: basic and contact information, contact persons, supporting documents
• Special features: several specializations, individual templates for specialist examinations, assignment to areas, personal work schedule

Maintaining an EHR

• Quick search
• Viewing medical records
• Recording all interactions with the patient
• Displaying cause-and-effect relationships
• Managing access to medical records
• An electronic analogue of a patient’s medical record with the ability to create a copy of it on hard media
• Personal data: basic and contact information, insurance policies, contracts
• Specialized medical information: health group, benefits, drug intolerance, observation history, etc.

Operating cash

• Registration of medical services under OMC, VHI, several sources of financing, and in cash
• Payment for services in cash with the generation of fiscal documents
• Current information about patient debts

Doctor's offices, treatment rooms and operating rooms

• Examination and medical history, registration of main and accompanying diagnoses
• Formation of a treatment plan, maintaining sick leave
• Treatment templates, dental map
• Registration of medical exemptions and patient refusals
• Accounting and control of issued prescriptions
• Issuing referrals for diagnostics, hospitalization, etc. with printing option
• Registration and follow-up
• Medical examinations: preliminary, periodic using templates
• Vaccine - prevention
• Registration of medical services provided with the possibility of automatic write-off
• Preparation of medical records

Functional diagnostics

• Possibility of attaching an unlimited number of files, with arbitrary additional information of any format, as well as viewing them
• Unified printing forms
• Doctor's report

Clinical diagnostic laboratory

• Ergonomic laboratory workstation
• Placing orders for research
• Registration of the place and time of the study
• Automatic substitution of related services
• Performing research in two modes: urgent (cito) or normal
• Reference values ​​of analyzes
• Research levels
• Research assignments
• Medical quality control of performed studies
• Printable forms of research results
• Sending test results electronically

Day hospital

• Bed capacity
• Reception department
• Hospitalization
• Electronic medical history

Pharmaceutical warehouse, pharmacy

• Sales of pharmaceutical products
• Pricing in accordance with the legislation of the Russian Federation
• Ergonomic workstations of the chief executive and pharmacist's workstations
• Trade equipment support
• Analysis of sales and trade margins
• Medicines accounting
• accounting of pharmaceutical groups, release forms, EGC
• indication of the international nonproprietary name, dosage
• inclusion in the mandatory range, vital and essential drugs
• accounting for different units of measurement
• accounting of certificates and expiration dates, counterfeits
• the ability to maintain analogues (interchangeability) of goods

Financial and planning department

• Mutual settlements with counterparties
• Exchange with the Pharm-SM trading platform
• Exchange with accounting systems: “1C: Enterprise Accounting 8”, “1C: Accounting 7.7”
• Management and regulatory reporting

Medical statistics office

• Formation of registers of invoices for treated patients
• Work with insurance programs and their control
• Workstation for coordination of medical services under insurance programs
• Exchange with the Federal Compulsory Medical Insurance Fund
• Exchanges between remote databases, synchronization of directories and data
• Statistical and regulatory reporting

New in version 1.00.14

1. General.

• From 01/01/2010, in accordance with the Decree of the Government of the Russian Federation of August 8, 2009 No. 654, the procedure for applying maximum wholesale and maximum retail markups to the prices of medicines is changing. The sale of medicines by wholesale trade organizations is carried out with the obligatory execution of a protocol for agreeing on prices for the supply of vital and essential medicines. To store and analyze data from the price register, the information register “Register of prices for vital drugs” has been added. Data loading is performed using the electronic document upload/download mechanism. A typical loading setting is supplied with the configuration and is located in the “Information register loading settings” group.

• The mechanism for viewing the register of medicines data from the “ITS MEDICINE” disk and creating elements of the “Nomenclature” reference book on their basis has been improved, the method of data exchange has been changed, now the data is transferred through a file on the disk, the web service has been removed, and the ability to batch generate nomenclature has been added.
• A mechanism for receiving, storing and processing data on rejected batches of medicines has been implemented. Information is obtained from external publicly available resources on the Internet (from the official website of the Ministry of Health and the website of the Pharmaceutical Association Foundation) in the form of mdb and dbf files.

When goods arrive, batches are checked against the list of rejected batches stored in the information register. If falsified series are detected, a comparison form opens in which you can set the “falsified” attribute for the series. Control of counterfeit documents when posting documents is determined by the right to “Check the movements of counterfeit documents.”

• A mechanism for monitoring the exceeding of the expiration date has been added to the documents “Receipt”, “Sales of goods”, “Receipt of goods”, “Movement of goods”, “Inventory of goods”. Control of exceeding the expiration date is established by the right to “Prohibit the sale of medicines with an expired expiration date.”

2. Logos of printed forms.

• A mechanism has been added to configure the display of medical institution logos in printed forms of documents.

3. Patient medical records.

• The procedure for assigning and storing patient medical record numbers has been changed. Added the ability to control the format of the medical card numberer.

4. Accounting for strict reporting forms.

A block for recording strict reporting forms has been added (forms for payment for services rendered, prescriptions, sick leave certificates...). This block allows you to automate the following types of accounting of strict reporting forms:

• Receipt of forms at the institution
• Issuance of forms to a specialist
• Writing off forms
• Fixing patient payment for services provided

• Added the ability to create patient examination protocol templates (in HTML format) used in the “Specialist Appointment” document with interactive filling of examination indicators.

New in version 1.00.13

The principles of operation and display of schedules of specialists and offices have been changed:

• The principle of storing employee specializations and linking work schedules to a specialist has been changed,
• The display of specialists and offices by departments and specializations has been changed,
• Added automatic schedule update (with the ability to configure the update interval),
• Introduced display and blocking of time intervals currently in operation,
• Implemented overlapping of work schedules for specialists and offices (in both directions),
• Added the ability to clarify the work schedule of a specialist or office (quickly edit the types of work schedule intervals in the Outpatient Workstation).

2. Added the ability to maintain a list of services provided by the counterparty, as well as the ability to attach an external printed form to each service provided and enter the name accepted from the counterparty.

3. Added the ability to select an external printing form for research and an external counterparty performing the research.

4. Added visibility control for departments displayed in the schedule of specialists and offices.

5. For automated workplace “Outpatient”:

• Added the ability to create a “Diagnostic Studies” document with automatic substitution of the Counterparty and the Settlement Agreement, selected interactively (Diagnostics tab),
• The principles of operation and display of schedules of specialists and offices have been changed (Schedule tab),
• Added the ability to create payment documents based on the “Admission coupon” documents and internal directions (Payment tab).

6. Identified errors have been corrected.

1c Franchisee "ABS" (Automation of business systems)

Who will benefit from this software?

Today, there are two programs related to this product - for use in a pharmacy, and for maintaining outpatient records in a healthcare institution. In other words, the described software can be effectively used in any government or commercial enterprise that requires automation of certain stages of the provision of medical services. In addition, each of these two programs is an effective means of keeping records of financial expenses and profits of an enterprise.

Product Features

The Outpatient program contains many functions necessary to cover the full cycle of work of any healthcare enterprise. The main ones are listed below:

• Registry. Maintaining a patient database; medical staff work schedule; home visit schedule for doctors; pre-registration for an appointment.
• Doctor's workplace. Patient medical records in electronic version; information about referrals for examinations, procedures or operations; maintaining sick leave records.
• Operations and procedures. Scheduling; fixing the time, place and conditions of the event.
• Accounting for drugs and medical materials. Access to the database of props available in the warehouse.
• Payment. Automatic calculation of the cost of providing services provided.

Practical effect of the program

The software, developed more than three years ago, has become widespread in medical institutions of our state. As practice shows, the product makes it possible to significantly optimize the workflow at all stages - from the patient’s admission for treatment to discharge after full recovery.

The speed of conducting examinations and processing tests is significantly increased, which makes it possible to more quickly prescribe medications, prescribe procedures to a patient, or send him for surgery. In addition, the influence of the human factor, which, as is known, often leads to tragic mistakes, is reduced.

Buy 1C Ambulatory today and you will receive it for free:

• delivery in Moscow and regions;
• installation;
• first 3 months of service and consultations.

If necessary, after 3 free months of service, we will be happy to conclude a support agreement on preferential terms.

Slide 2 of xx Why this solution is needed Helps medical organizations take a comprehensive approach to organizing the treatment process, managing economic and financial activities in accordance with the legislation of the Russian Federation

Slide 3 of xx June 20, 2013 Compliance with state standards Providing medical care and maintaining records in accordance with state standards: Protocol for patient management (OST PVB) Simple medical services (OK PMU N) Complex and complex medical services (OK N) Outcome classifier diseases Classifier of disease complications Classifier of specializations Classifier of pharmacotherapeutic groups International classifier of diseases (ICD10)

Slide 4 of xx For whom it is intended State and commercial medical organizations: Clinics, hospitals, dispensaries Diagnostic and specialized medical centers medical centers Rehabilitation and rehabilitation centers Doctors and massage rooms

Slide 7 of xx Maintaining mutual settlements Supported types of payments Payment for a completed case Payment for a one-time visit Formation of registers for treated patients OMSDMS Under agreements with legal entities. persons Payment in cash Support of insurance programs Control of insurance programs Coordination of medical services Accounting for letters of guarantee

Slide 8 of xx Abbreviated automation scheme Registration Operating cash desk Medical statistics office What does the work schedule of medical personnel Manage the workload of specialists, offices and hospital beds Manage the queue of patients Control of services provided under compulsory medical insurance, voluntary medical insurance Formation of registers for payment for treated patients Management of goods and materials Maintaining mutual settlements Generating reports for FPO Pharmacy warehouse

Slide 9 of xx Abbreviated automation scheme Advantages Creation of a unified information space of the enterprise Patient flow management: Rational resource management Control of mandatory appointments Reminders via SMS and Centralized registration of services for compulsory medical insurance, voluntary medical insurance and cash payments Reductions in the staff of data entry operators: Loading data of the registered population from email documents Introduction of bar coding of primary documents Elimination of duplication of data entry Reduction of refusals to pay health insurance providers for treated patients Reduction of errors associated with the human factor Relatively low cost

Slide 10 of xx Full automation scheme Registration Operating cash desk Medical statistics office Maintaining the patient's EHR Work of medical personnel Clinical diagnostic laboratory Functional diagnostics Treatment and operating rooms Hospital Pharmacy warehouse

Slide 11 of xx Full automation scheme What gives All the advantages of a shortened automation scheme Improving the quality of medical care due to: Rapid access to medical documentation Application of treatment standards, monitoring their implementation Automated control over the provision of medical care at all stages of its provision Integration with medical equipment Maintaining electronic document flow and its standardization Maintaining an EHR Reducing costs by eliminating the re-appointment of medical services Timely information about patient debts, control of mutual settlements Possibility of personalized accounting of services and inventory items spent on treatment

Slide 15 of xx June 20, 2013 Structure of a medical organization Multi-company accounting Company divisions Unlimited level of nesting Arbitrary structure Remote divisions Communication of divisions with employees with employees

Slide 16 of xx June 20, 2013 Employees Personal data Basic information Contact information Contact persons Supporting documents Special capabilities Several specializations Individual templates for specialist examinations Attachment to areas Delineation of rights

Slide 18 of xx June 20, 2013 Information about the patient Personal data Basic information Documents Contact information Family composition Specialized data Health group history Insurance policies Medical withdrawals and refusals Observation history Methods of mutual settlements Compulsory health insurance VHI Cash payment

Slide 19 of xx June 20, 2013 Health insurance policies Compulsory health insurance policies (CHI) Voluntary health insurance policies (VHI) Indication of the insurance program Duration of the policy Indication of affiliation with compulsory medical insurance Assignment of the status “Invalid”

Slide 20 of xx June 20, 2013 Insurance programs Control of the amount of payment provided under the program Control of services provided under VHI Indication of prohibited diagnoses and specializations Rules for control of services: without restrictions, by quantity, by agreement Indication of the number of UET

Slide 21 of xx Maintaining mutual settlements Automatic calculation of the cost of services provided Control of mutual settlements with patients at all stages of diagnosis and treatment Generation of payment documents Payment for services in cash with the generation of fiscal documents Mixed form of payment: for cash and insurance policy Operational information about patient debts

Slide 22 of xx Nomenclature Setting up accounting for various types of items Setting up accounting by characteristics Control of prices by characteristics Various barcoding conditions

Slide 23 of xx Nomenclature Medical services Simple, complex Manipulations Diagnostics Write-off inventory items Related services Performance schedules Medicine. Products Consumables KitsKits

Slide 24 of xx Accounting for batches of medicines Batch-by-batch accounting by batch The batch is unique within the nomenclature position Automatic generation of the batch name based on the entered data Possibility of using the manufacturer’s serial number Assigning the “Do not use” status to the batch Expiration date of the batch

Slide 27 of xx Rules for the pricing of medicines Assignment of rules for pricing a product item for each department Control of the minimum and maximum markup Corridor of “No changes” prices Control of the minimum balance in warehouses Indication of the frequency of order formation

Slide 28 of xx June 20, 2013 Registration Ergonomic and intuitive reception desk Convenient registration of new patients Quick search for patients Making an appointment and calling a specialist to your home Viewing the workload of specialists

Slide 29 of xx Work schedule of medical personnel Assignment of the work schedule of specialists For the entire organization Per department Personal Planning of staff working hours

Slide 30 of xx June 20, 2013 Electronic Medical Record Quickly search a patient's electronic medical record Capture all patient interactions Display cause-and-effect relationships

Slide 31 of xx Reception of a specialist Doctor's workplace Collection and registration of anamnesis Referral for diagnostics Registration of diagnoses Drawing up treatment plans Formation of appointment sheets Work and rest schedule Collecting and registration of anamnesis Dietary prescription Registration of services performed Maintaining sick leave Printed forms of documents Appointing the time of the next appointment

Slide 32 of xx Appointment with a specialist Collecting and recording anamnesis Displaying the patient's life history Arbitrary types and types of anamnesis Examination results Formation of a treatment plan Medicines and method of administration Therapeutic and preventive measures Dietary prescriptions Referrals for: Diagnostics Appointment with a specialist Hospitalization Procedures and operations Vaccination

Slide 33 of xx Appointment with a specialist Dispensary registration Registration and deregistration Observation plan Observation templates

Slide 34 of xx Appointment with a specialist Medical examinations One-time examination Periodic examination Using templates Appointment of time for the next examination

Slide 35 of xx Vaccine - prevention Dosages Vaccination calendar Type of vaccination Types of immunization Reaction results

Slide 36 of xx Dentist appointment Electronic dental chart Indicating dental conditions Attaching x-rays to the dental chart

Slide 37 of xx Diagnostics Diagnostic departments: Clinical and diagnostic laboratory Functional diagnostics General functionality: Placement of orders for studies without referrals, based on external and internal referrals Registration of the place and time of the study Automatic substitution of related services Performing studies in two modes: urgently (Cito) or normal Possibility of attaching an unlimited number of files, with any doctor’s opinion

Slide 38 of xx Clinical diagnostic laboratory Flexible settings system: Arbitrary groups of patient norms and types of research results Reference values ​​of analyzes depending on the group of patient norms, research methods and arbitrary characteristics Automatic substitution of a priority research method when placing a patient order

Slide 39 of xx Clinical diagnostic laboratory Formation of an order for research Automatic substitution of related services Support for the “Cito” mode Research stages Support for research panels Printing forms Issuing test results Monitoring the issuance of results

Slide 40 of xx Clinical diagnostic laboratory Ergonomic laboratory workstation Formation of an order for research Possibility of performing the same study using several methods Automatic substitution of a priority research method when placing a patient order Generation of a unique barcode for each tube

Slide 41 of xx Diagnostics Functional diagnostics Unified printed forms Possibility of attaching various files: DICOM, MEDICOM Doctor’s conclusion

Slide 42 of xx Hospital Case management Admissions department Data on the patient’s condition upon admission Collecting and recording anamnesis Registration of diagnoses Medical exceptions and refusals Data on accompanying diagnoses Printing an extract Taking into account the patient’s values ​​Convenient viewing of bed status

Slide 43 of xx Pharmacy Possibility of barcoding of each series Prescription supply Analogues of medicines Inclusions in the mandatory range Automated control of counterfeits and expiration dates of the Mandatory range Trade margins for deviations from the maximum permissible

Slide 44 of xx Accounting for batches of medicines Batch-by-batch accounting by batch The batch is unique within the nomenclature position Automatic generation of the batch name based on the entered data Possibility of using the manufacturer’s serial number Assigning the “Do not use” status to the batch Expiration date of the batch

Slide 45 of xx Ordering pharmaceutical products Flexible assortment management Placing an order from one supplier or from different ones Various parameters for the strategy for selecting the best supplier Analysis of supplier price lists Automatic creation of orders

Slide 47 of xx Movement of goods Ergonomic workstation of the “Storekeeper” Support for the operation of order and cellular warehouses Possibility of revaluation of goods using movement documents Filling out the tabular part of the document Warehouse balances Reserves for orders Department reserves

Slide 48 of xx Accounting for medicines and materials Friendly automated workplace of the storekeeper Capitalization taking into account series Support of order and cell warehouses Inventory, movement and write-off Control of the minimum balance in the warehouse Return to the supplier Slide 50 of xx Conducting business activities Accounting for cash flows Payroll Management of enterprise assets, depreciation Revaluation of foreign currency funds Planning of cash receipts and expenditures Budgeting Client-Bank Preparation of regulatory documentation All types of cash transactions

Slide 51 of xx Reports Analysis of medical activities Statistics of calls to specialists Logs: case histories, calls to a specialist, notes to a specialist For vaccinations and medical examinations Passport: therapeutic area, pediatric area Dispensary records Medical withdrawals and refusals For medical services provided Analysis of services provided Accounting for agency services

Slide 52 of xx Exchange with other systems Exchange with the Compulsory Medical Insurance Fund Uploading and downloading data Uploading compulsory medical insurance directories Formation of a register of services provided Loading the register of insured citizens Exchange with the accounting system “1C: Accounting 8” “1C: Accounting 7.7” Data exchange between departments Data exchange with geographically remote departments Data exchange with remote cash desks

Slide 53 of xx Connecting trade equipment Programmable keyboard Data collection terminal Fiscal recorder Barcode scanner POS system

Slide 54 of xx Pricing Name Retail price for the end user, rub. Outpatient clinic 1 + Persons 1 RM Persons 1 RM Outpatient clinic Persons 5 RM Outpatient clinic

The relevance of creating an information system in medical institutions today is due to the need to use large and constantly growing volumes of information when solving diagnostic, therapeutic, statistical, management and other problems.

Informatization of the activities of healthcare institutions has long become not just a tribute to modern trends, but an urgent necessity. Processing ever-growing amounts of information has become possible only with the use of modern computer technologies.

It's no secret that most of the appointment is spent not on resolving clinical issues, but on accompanying and far from the most basic work - preparing outpatient coupons and other reporting documentation, entries in the outpatient card or medical history, appointments for consultations or examinations, etc. d. There is no longer any doubt that the most effective tools for facilitating the work of medical staff and increasing their efficiency are computer technologies. Automation can not only make work easier, it should free staff from routine and give them a fundamentally new tool, which, directly or indirectly, will lead to a reduction in the waste of intellectual baggage, the realization of the desire to work and practice medicine.

The main goal of the course work is to reduce the time spent by the registrar by automating the main processes: “Registration of a patient”, “Providing preliminary and urgent registration of patients for appointments”, “Providing reference information”, “Statistical analysis”.

To achieve these goals, it is necessary to complete the following tasks:

analysis of business processes for working with patients at the reception;

analysis of the current state of automation of the subject area;

determining system requirements;

software development;

development and execution of documentation;

implementation of a software product.

1.Analysis and review of existing developments in the subject area

In the process of studying the current state of domain automation, the following software products were considered:

ArchiMed Company product, “Registration” module

Registry– module of the automation system for medical institutions ArchiMed, designed for registering patients, establishing and printing outpatient cards, scheduling the work of specialists, recording patients for appointments, printing coupons. The average cost of the product is 15,000 rubles.

Main features of the module:

building multi-level groupings based on data;

extensive filtering capabilities;

drawing up a work schedule for an arbitrary period of time;

quick search for a patient's card in the card archive;

recording a patient without creating an outpatient card (the card is created directly during a visit to the facility, which allows you to reduce the number of unused electronic outpatient cards in the archive);

tracking by status (Record, Arrived, Partial payment, Full payment, etc. Status switching occurs automatically, specified when setting up the system);

the ability to transfer patient data from other systems using special plugins (for example, transferring guests in the “ArchiMed-sanatorium” configuration from the UCS Shelter hotel system);

registration of doctors' home visits. Print a card with the call address.

Medtime, automated workstation (AWS) “Registration”

Medtime, automated workplace Registration. At the moment, maintaining documentary records of patients takes up most of the doctor’s working time, but at the same time it is a necessary attribute of any medical institution. The proposed medical information system allows you to keep a full record of the medical services provided to the patient, automatically generates the necessary medical documentation (initial examination, diaries, protocols of additional studies, extracts, standard forms for medical institutions), compiles detailed reports on the work of the hospital and personnel according to established statistical and arbitrary forms.

Medtime features:

the ability to automate routine operations performed by clinic reception staff, allowing them to do their work more quickly and efficiently;

the ability to more efficiently and quickly organize the procedure for receiving patients and scheduling them with medical specialists;

the ability to optimally schedule doctors’ appointments, eliminating the possibility of making mistakes;

generate and print medical documentation necessary for the operation of the registry.

1C-Rarus: Ambulatory, edition 1

The 1C-Rarus company offers software products for complex automation of medical institutions. Clients of 1C-Rarus in the healthcare sector are government and commercial medical organizations, multidisciplinary clinics, clinics, dispensaries, specialized medical centers, health and rehabilitation centers, medical and massage offices.

The standard solution “1C-Rarus: Ambulatory, edition 1.0” is intended for complex automation of medical institutions providing outpatient care to patients, which are both single and network structures. The solution allows you to improve the quality of patient care, provide medical services under compulsory medical insurance, voluntary medical insurance and in cash, keep records of medical services according to the standards of the Ministry of Health and Social Development of the Russian Federation, plan the work of medical personnel, take into account inventory items, carry out medical and financial control of activities enterprises, carry out mutual settlements with counterparties.

The solution "1C-Rarus: Ambulatory, edition 1.0" accumulates methodological solutions and accumulated experience of the 1C-Rarus company in the automation market of medical organizations, such as the Stem Cell Bank "CryoCenter", LLC "EL-CLINIC", Therapeutic Cosmetology Clinic " UNASKIN." The average cost of the product is 65,000 rubles.

The cost of these projects ranges from 18,000 to 70,000 rubles. The advantages of these projects are the implementation of many functions for the registrar, such as searching for an outpatient card, tracking the patient's status. The downside of these products is the high cost and modification of the programs on site in order to adapt the software product to a specific medical institution, which again increases the price of the product. The authors of the course propose to reduce the cost of developing automated workstations and gain practical experience in creating applications in Microsoft Visual Studio.