This module is required, to be fully, integrated with, inpatient management and patient accounting. This module should support the operational needs of a modern medical records department including transcription, case indexing, abstracting, statistical reporting, charge location, with complete integration with patient billing function.
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.
| Medical Records |
| | Description | | This module is required, to be fully, integrated with, inpatient management and patient accounting. This module should support the operational needs of a modern medical records department including transcription, case indexing, abstracting, statistical reporting, charge location, with complete integration with patient billing function. |
| 1 | | Automatic and manual assignment of medical record numbers to patients not found in Master Patient Index | | 2 | | Allow for error correction and merging of duplicate patient records | | 3 | | Support on-line maintenance and access to medical records for inpatients, outpatients, and emergency patients. | | 4 | | Provide a Master Patient Index ( MPI ) containing patient demographic, insurance and diagnosis data for all hospital visits. | | 5 | | Automatically update MPI based upon entry and update of patient data in admissions or registration | | 6 | | Provide storage capacity to retain MPI data permanently | | 7 | | Allow authorized medical records staff to merge to medical records for same patient | | 8 | | Allow reuse of medical record number if used in error | | 9 | | Support medical records abstracting | | 10 | | Retrieve patient demographic data from admissions system and/or MPI into abstracting functions | | 11 | | Retain all diagnoses during patient stay for abstracting purposes | | 12 | | Support user-defined fields for hospital’s unique abstracting needs | | 13 | | Provide on-line help screens to assist in abstracting process | | 14 | | Generate abstracting productivity statistics on amount of work completed and time spent per chart | | 15 | | Support ICD-10 coding and online maintenance | | 16 | | Support Current Procedural Terminology – Fourth Generation ( CPT-4 ) | | 17 | | Provide updates of ICD-10 and CPT-4 code files required by regulation changes | | 18 | | Maintain and provide ability to display hospital-specific coding procedures and guidelines | | 19 | | Automatically edit coding entries to insure valid order of codes ( e.g. principal diagnosis as 1st and specific complication as 2nd ) | | 20 | | Include context-sensitive coding prompts and instructions to ensure complete coding | | 21 | | Provide “quick entry” feature that replaces long medical terminology after short abbreviation is keyed | | 22 | | Support “reasonableness” edit checks to insure proper coding ( e.g. patient sex correlate with procedure ) | | 23 | | Support current and past DRG groupers for previous two years on the system for use at the same time | | 24 | | Provide option for DRG optimizing to assess alternative coding and expected reimbursement | | 25 | | Provide an automated birth log | | 26 | | Provide an automated death log and bereavement form | | 27 | | Provide automated tumor registry functions | | 28 | | Bar code capabilities to facilitate record reading and data entry |
| 29 | | Patient data :- Demographic patient data | | 30 | | Patient data :- Outpatient data | | 31 | | Patient data :- Current administrative data | | 32 | | Patient data :- Confidential records | | 33 | | Clinical data :- Test results | | 34 | | Clinical data :- Medications | | 35 | | Clinical data :- Vital signs, allergies | | 36 | | Clinical data :- Orders | | 37 | | Clinical data :- Nursing documentation | | 38 | | Clinical data :- Graphical display of data , automatic plotting of results |
| 39 | | On-line search of MPI by patient name | | 40 | | On-line search of MPI by patient name with soundex ( phonetic ) search capability | | 41 | | On-line search of MPI by Social Security Number | | 42 | | On-line search of MPI by Medical record number | | 43 | | On-line search of MPI by alternate name ( e.g. maiden name , father’s , mother’s) | | 44 | | On-line search of MPI by patient birth date |
| >>> Medical Record Tracking | | | | 45 | | Track status of all required data to complete patient’s medical record folder at discharge | | 46 | | Allow for reserve of Medical Charts by authorized Staff | | 47 | | Allow to change location of Medical Records | | 48 | | Provide chart control functions that track chart location by physician or other members | | 49 | | Produce an automated ‘picking list’ of charts to be sent by bulk ( i.e. to the clinics ) , based upon the appointments system | | 50 | | Generate chart out-guides and chart routing slips to assist in chart control | | 51 | | Track incomplete charts and missing data required for completion | | 52 | | On-line inquiry for all not found in / returned to the Medical Records department | | 53 | | Print reminder letters and reports monitoring location of the records checked out | | 54 | | Enable users to view any record and display the record’s current location | | 55 | | Support merging and deletion of Medical Records | | 56 | | Generate an audit trail and recipient inquiry | | 57 | | Warn for duplicate or incomplete records | | 58 | | Incomplete Medical Records check |
| >>> Reporting and Print Options | | | | 59 | | Print daily chart retrieval lists for all patients with scheduled visits | | 60 | | Print chart request notice in Medical Records for unscheduled admissions and registrations | | 61 | | Production of bar-coded labels | | 62 | | Print incomplete medical record delinquency reports by physician showing deficiencies | | 63 | | Print deficiency, suspension and reinstatement letters for physicians | | 64 | | Provide ability to report abstract data on magnetic media and other interfaces medias ( e.g. tape or disk ) for reports to outside agencies ) | | 65 | | Print aging report of all checked out charts by location in hospital | | 66 | | Produce deficiency report for physicians and specialties | | 67 | | Produce deficiency report for diagnosis and procedures | | 68 | | Print incomplete coding reports | | 69 | | Print ICD-10 attestation statements for physician signing | | 70 | | Print statistical report of admissions | | 71 | | Print statistical report of discharges | | 72 | | Print statistical report of deaths | | 73 | | Print Statistical report of occupancy percentage | | 74 | | Print statistical report of patient days | | 75 | | Print report of physician activity by medical service | | 76 | | Print list of physicians with suspended admission privileges | | 77 | | Pint list of physicians with suspended clinical privileges | | 78 | | Maintain user activity log | | 79 | | Maintain monthly log of new medical records |
| 80 | | Statistical Report of admission by service and admitting diagnosis | | 81 | | Statistical report of discharge by service by discharge diagnosis | | 82 | | Statistics by discharge diagnosis to include: Frequency, age groups, percent of deaths, gender , actual length of stay | | 83 | | Statistics by primary discharge diagnosis and secondary diagnosis to include: Frequency, age groups, percent of deaths by age group, gender, actual length of stay |
| 84 | | Maintain abstracting data on-line for three years | | 85 | | Maintain sensitive archiving facilities | | 86 | | Maintain discharge summary of inpatients in various formats | | 87 | | Perpetually maintain the patient index as per set criteria |
| 88 | | A visit history which lists visits, providers visited, and when | | 89 | | A history of the patient’s encounters | | 90 | | A list of all patients’ visits, along with the diagnosis associated with each visit. | | 91 | | Medical history and test results |
| 93 | | Inpatient and Outpatient modules | | 95 | | Order entry and results reporting |
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In this section you'll find a list of companies and organizations working in the healthcare IT sector in Egypt.