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. |
| 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 |
| 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 |
| 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 |
| 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 |
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