Chapter 5

Patient Management

Patient Management
Patient Master Data
The system contains one master data record for each patient. This record is the
central element linking all administrative, medical, and nursing care data. As a
result, both outpatient and inpatient procedures are made available via a single
view.

Central Patient Master

Record

Fig. 5-1: Patient Master Record and Related Information

A patient is identified in the IS-H System by a unique 10-digit patient identification number which is valid throughout the life cycle of the system. The system
requires no specific semantics; the patient identification can be designed according to your requirements and can be established, for example, as an:

Unique Patient Number

q An internally assigned consecutive number with a check digit

Internal and External

Number Assignment

q An externally (manually) assigned number to which you add a check digit

q An externally assigned alphanumeric patient number
Together with the identifying patient number, another number can be assigned
which can be defined, for instance, as an I-number. This allows you to switch from
the I-number method to a nonmnemonic patient number when IS-H is implemented.

I-Number

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Case Assignment

Every case for a patient is assigned to the corresponding master data record and
receives a case number unique for the corresponding healthcare institution. The
case number as well as the patient number can be assigned manually or automatically.

Patient Search Using

Combined Attributes

In a patient-oriented system it is essential to maintain a consistent patient database. To do this, you need to determine the correct patient master record both
when admitting previous patients whose master records are already in the system, and when processing other patient-related data. Usually, the patient master
record is not selected by entering the patient number, but by using descriptive,
patient-related information. There are two possible ways to search for a patient:
either by entering combinations of patient-specific attributes (see Fig. 5-2):

Search Attributes

q Last name
q First name
q Birth name
q Date of birth
q Gender

Search by Movements

Or using movement lists, such as patients admitted during a certain period to a

selected organizational unit.

Fig. 5-2: Patient Index Search

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Patient Management

This search using patient attributes allows you to search for a name by entering
only part of the name (generic entry). Due to name standardization, the search
function is not case sensitive. You may also search for compound names and former
names. For last names, the phonetic search according to a freely selectable phonetic method is also supported.

Name Standardization
Phonetic Search

Depending on the parameters set for your system, you perform a search using all
patients or - if this is not desirable, or if you are restricted by data security considerations - a limited search for a specific institution is possible.
If the search attributes apply to several patients, the patients found are displayed
in a list for subsequent selection. If it is not possible to identify a patient using the
specifications in the list, additional data is available via a dialog box (see Fig. 5-3).

Selection Lists

Fig. 5-3: Selection List of Patients found in the Database

As an alternative to entering the search criteria manually, you can import data
from a healthcare smart card into the IS-H System and use it for the patient search.

Healthcare Smart Card

One common way to search for patient master records is to use movement lists.
Using this approach, you search for patients by movement and case-related attributes. Examples are lists of all patients who were admitted, transferred, or discharged during a certain period or who made outpatient visits or were registered
through quick or emergency admission during that period. These latter lists are
particularly important for selecting quick and emergency admissions for further
processing.

Patient Search Using

Movement Lists

As stated earlier, a consistent patient database requires that exactly one patient
master record is created for each patient. To ensure this consistency, IS-H offers
several features which can be activated by the user:

Unique Patient Master

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Patient Management

q Convenient patient search options

q Mandatory search for any existing patient master record when creating a new
record
q Interactive verification to ensure that no duplicates are present before the new
patient master record is saved.

Patient Record Merging

If a second patient master record was created for a particular patient, this new
record can be merged with the existing record. Related information (such as cases,
movements) will be retained.

Patient Movement
Different Movement
Categories
Optimum Support of
Work Processes

Patient movement refers to any change affecting the patient stay with respect to
location or organization, such as admission, transfer, or outpatient department
visits. These different movement categories may be processed in separate system
functions. To provide optimum support of work processes, you can manage the
actual movement data and also the patient and case data depending on the category of movement. IS-H documents different categories of patient movements
for inpatient and outpatient cases. Companions and newborns are also taken into
account and assigned movements accordingly.

Patient Admission
Admission is the main function for entering patients in the IS-H System. You use
the function to enter all data required for administrative, medical, and nursing
purposes during the patients hospital stay.

Patient and Case Data

Outpatient and Inpatient
Admission Method
Sub-Functions

During patient admission, both patient- and case-related data are processed. The
amount of data depends on the admission method selected (standard, quick, or
emergency admission). Outpatient, observation patient, and inpatient admission
are basically structured in the same way, but differ somewhat with regard to the
type and amount of information to be entered.
Admission basically includes the following sub-functions:
q Patient index search
q Patient master data
q Admission/referral data
q Diagnostic data
q Accident data
q Insurance relationships/treatment certificates
q Services

Flexible User Interface

All functions also allow you to display or suppress fields from the screen. You also
control which sub-functions to carry out and in what order.

Patient Admission offers functions which are suitable for the hospital work processes
involved in the admission of inpatient and outpatient cases.

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Patient Management

Standard Inpatient Admission

The standard admission screen contains all functions and fields to be completed
for patient admission.
The interactive admitting process begins with the patient search; you have to determine whether the patient is new to the system and a record has to be created or
whether he/she is a previous patient whose master data has only to be verified
and updated, if necessary.

Patient Index Search

The patient master data contains all attributes applicable to the patient regardless
of each individual case.
Once the patient master data has been entered or verified, the actual case is processed. If the patient is a previous patient, his/her case list will be called up (see
Fig. 5-4). At this point, you can decide whether to continue an existing case or
create a new one. A case would be continued if, for example, a scheduled patient
is admitted.

Case List

Fig. 5-4: Case List of a Patient

When admitting the case, all data relevant to the patients current hospital visit is
entered (see Fig. 5-5).

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Patient Management

Fig. 5-5: Case with Related Information

Admission Data

q Admission data such as date and time of admission, admission type, reason
for the admission, planned length of stay, accident data, emergency indicator,
admission status (waiting list/planned/actual), etc.
q Patient assignment. Each patient can be assigned to a:

Nursing Care and

Specialty Assignment
Room Assignment

m Nursing organizational unit such as a nursing station.

m Specialty organizational unit such as the department involved.
m Room and/or a bed.

Multi-Specialty Assignment

q All system functions including Controlling support the distinction between

specialty and nursing responsibilities. This allows an easy and correct representation of multi-specialty assignments. The system also supports two-level
admission procedures where the patient is first assigned to organizational units
only, then later to a bed, for instance, on the nursing station.

Admission Data

q Admission data such as the referring physician, referring hospital or the referral diagnosis.

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q Multiple insurance relationships between patient and insurance providers;

when self-pay patients are admitted, open items can be displayed from
Accounts Receivable.

Insurance Relationships

q Services to be provided to the patient such as nursing charges, personal items,

but also individual services such as laboratory tests or a flat rate per case.
Requests for insurance verification directed to the respective insurance providers can be generated directly for the billable services entered.

Services

Fig. 5-6: Admission Data for Inpatient Case

Various catalogs and overviews (e.g. postal data, physicians, hospitals, diagnosis
code catalogs, etc.) are available in the admission procedure to simplify input. The
system also contains a patient census indicating available rooms and beds as well
as current bed assignments for specific patients. This allows optimum distribution of available bed resources as well as the most suitable room assignment. This
nursing station overview may be displayed as a table or in a graphical format (see
section Nursing Station Management).

Patient Census Overview

Admission is further facilitated by automatic input functions such as geographical areas. Parameters can be set for automatically generating service and billing
data by entering the treatment category (e.g. generating the basic nursing charge,
semi-private room surcharge and chief physician choice for private patient, semiprivate room).

Automatic Input Functions

During or after completing the admission procedure, definable work organizers

can be created, such as patient master sheets, labels, or admitting release forms.

Work Organizers

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Patient Management

Planned Admissions

The entire admission process may be performed on the planning level or by waiting lists. In this case, you only need to check and/or supplement the planned data
when the patient actually arrives. This reduces the workload during peak admission periods and greatly increases the quality of the admission process.

Standard admission enables you to enter all required patient and case data, including bed
assignment if necessary.

Standard Outpatient Admission

Outpatient Case

During standard outpatient admission, patient data is processed and an outpatient case with a first visit is created. The process is similar to inpatient admission
with the exception of the data which pertains specifically to the outpatient area.

Data Required for

Outpatient Admission

In addition to patient master data, outpatient admission requires the entry of data
such as:
q Visits
q Patient assignment
q Referral data
q Treatment certificates
q Services

Outpatient Department
Planning

As an alternative, outpatient department planning can be used for outpatient admission by simply scheduling an appointment for a free time slot. Both physicians
and treatment rooms can be scheduled (for more information see the chapter Outpatient Department Management).

Fig. 5-7: Outpatient Case

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Patient Management

If treatment for an outpatient is to be continued in the hospital, the outpatient case

can easily be converted to an inpatient case. This supports the required transparency between outpatient and inpatient treatment areas.

Change of Case Type

Outpatient emergency admission enables you to enter all patient and case information
pertaining to outpatient cases.

Quick Admission (inpatient and outpatient)

A complete patient admission requires you to enter extensive data on the patient
and his/her case. The dialog for this procedure consists of several screens. In cases where there is a high workload, shortage of departmental staff, or missing data,
the admission should still be performed as quickly as possible. IS-H provides an
abbreviated admission function with only the minimum amount of data required
for proper case processing at a later time. Patients admitted via quick admission
are marked as such and their complete data can be entered at a later date. Followup lists can be called up to remind you of such patients. This follow-up procedure
also applies to emergency admissions. If the admissions office is not staffed on the
weekend, the patient can easily be admitted to the respective nursing station, and
the missing data can be entered by the admissions office at a later time. Quick
admission is available both for inpatient and outpatient cases.

Quick Admission with

Minimum Data
Follow-Up

Inpatient and Outpatient

Quick Admissions

Quick admission allows you to quickly enter a case and add the missing data at a
later time.

Emergency Admission (inpatient and outpatient)

The emergency admission function is used to register patients who cannot be immediately identified or for whom a complete admission procedure is not performed. A prior patient index search is not mandatory for emergency admissions.
This form of admission is even more limited in scope than quick admission. Emergency admissions are marked as such in the system and must be checked and
subsequently completed using the standard admission function. Should you discover that the patient had already been entered in the system, functions are available enabling you to merge patient master records.

Incomplete Admission if
Identification Impossible

Complete at a Later Date

Emergency admission enables you to quickly admit patients who cannot be identified.

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Patient Management

Newborn Admission
Newborns as Patients

With few exceptions, newborns are entered as patients after birth and are managed in the system as a patient master record with an outpatient or inpatient case.
The newborns case is assigned to the mothers case.

Delivery Data/
Birth Data

When admitting a newborn, all statistically relevant delivery data is entered first,
such as the delivery method and time as well as the birth data of the newborn(s). In
case of a documented stillbirth, or if the newborn is not admitted after an outpatient
delivery, the admission process can be terminated at this point - the delivery data is
stored, but no case is created for the newborn. When you enter the master data and
admission data for the newborn, certain information is transferred from the mothers data record or the delivery data to make admission as simple as possible.

Assignment of
Multiple Births

In the case of multiple births, all the newborns may be admitted and assigned to
the mother in one procedure.

Time-Dependent Status
Information

The assignment between mother and newborn(s) does not depend on the admission method, so that outpatient and inpatient assignments are possible. Whether
the newborn is healthy or sick, which is important information for patient billing,
is stored as period-dependent status information together with the newborn case.

Newborns are normally entered into the system as patients with a related case, and
assigned to the mothers case.

Admission of Companions
Separate Cases for
Companions

Persons who accompany a patient and benefit from services are admitted as a
separate inpatient or outpatient case. The case is assigned to the related patient on
a time-dependent basis. One person can be the companion for several patients
and vice versa.

Assigning the Companion

to the Patient

The companions case is assigned to the patient who is accompanied either when
the companion is admitted or at a later date, if necessary.

Companions are also entered and their cases are assigned to the respective patient (s).

Outpatient Visit
Visit in the Outpatient
Department/Medical Service
Facility
Visits for Inpatient and
Outpatient Cases

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The planned or completed treatment of a patient in an outpatient department or a

medical service facility is entered as an outpatient visit. Such visits are possible for
outpatient cases, but also in the course of inpatient treatment or for an observation
patient. Both visits before and after an inpatient hospital stay (pre-admission and
post-discharge treatment) and during an inpatient stay (e.g. for a second opinion)
can be represented.

Patient Management

To enter and process an outpatient visit requires correct patient identification. Using the patient index search described previously, you may determine whether
the patient is returning or needs to be entered as a new patient. The respective
visit is then logged indicating the place and time and assigned either a Waiting
List, Planned, or Actual status. In addition, the outpatient department or medical
service facility providing treatment is specified.

Patient Identification

If a visit has already been documented via preregistration, it only needs to be

confirmed upon the patients arrival. The visit status changes from Planned to
Actual.

Scheduled Visits

Pre-admission or post-discharge treatments are entered as visits and are assigned

to the inpatient case as movements. These visits are identified as special visit types
with specific plausibility checks (e.g. maximum number of pre-admission treatments, maximum time interval between pre-admission treatments and inpatient
admission, etc.). The services billable for pre-admission and post-discharge treatments can also be assigned to the case and invoiced as such.

Plausibility Checks

Pre-Admission and
Post-Discharge Treatments

Outpatient visits are used to enter treatments in outpatient departments and medical service facilities and can be assigned to outpatient and inpatient cases.

Transfer
When a patient is transferred, the patients location is changed at organizational
and/or building unit level (departmental, nursing station, room, or bed location
transfers). Like all movements, transfers can also be performed in planning. When
a patient is transferred, other related information such as nursing category, diagnoses, case classification (e.g. chief physician choice), attending physician, companion have also be maintained if necessary.

Changes of Organizational/
Building Units
Planned Transfers

Fig. 5-8: Transfer

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Patient Management

Service Documentation

Since services performed for a case (for example, personal items, departmental
per diems) are always linked to specific organizational units , the extended services entered for the previous movement are automatically delimited (service split).
Services can also be processed manually to document added or deleted services.

Transfers are changes in the patients location at organizational and/or building

unit level; service data, diagnoses, etc., must also be processed.

Leave of Absence
Documenting Leave of
Absence

The periods of time during which a patient has temporarily left the hospital have
often to be tracked. This enables you to monitor the patients location and organizational assignment, calculate the care and operational services rendered, and react to changes (such as reduced nursing charges) within the accounting system.

Planned Leave of Absence

Leave of absence may also be entered in planning for a future time period by
specifying the leave of absence start and end dates in advance. In this case, the
data must be confirmed and modified (if necessary) when the actual absence occurs. In addition to the time frame, you also maintain the reason for the absence,
the approval, and the approving physicians, if necessary.

Periods of absence can be entered as planned or actual data, and are taken into account
for staffing, accounting, etc.

Discharge
Related Activities
Entering Discharge Data

When you discharge a patient, discharge data such as discharge type, date and
status, post-discharge physician or hospital have be entered. In addition, certain
activities related to the discharge are included in the processing flow, similar to
transfer processing. These activities include entering the discharge diagnosis, determining the hospital main diagnosis, or checking the nursing categories of the
case for completeness. IS-H provides these processing functions when the patient
is being discharged.
Planned transfers, absence periods, and other planned movements may be canceled or changed.

Final Check of Services and

Insurance Verifications

Extended services such as nursing care charges and personal items are ended automatically. You can double-check whether benefits coverage has been confirmed
by an insurance provider for every service performed. If necessary, the case can be
billed at discharge so that private patients receive the invoice upon discharge.

Assignment to Other Cases

Assignments to other related cases are also checked. A companion has to be discharged together with the respective patient, unless the person is a companion for

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other patients as well. The assigned cases may be discharged immediately after
the patient.
IS-H also supports planned discharges.

Planned Discharges

Fig. 5-9: Discharge

Discharges can be processed together with the corresponding sub-activities.

Pre-Registration
Every patient movement, from admission to discharge, may be entered in planning. For example, an admission can be entered for a future date. In this case, the
patients master data and admission data such as assignment to a specific department or applicable insurance relationships can be entered in advance.
Entering planned movements, including the services involved, becomes particularly important when performing resource or capacity planning.

Planned Movements

Resource Planning

For planned admissions in particular, it is sometimes not possible to specify the

exact date of the actual admission. In this case, the patient master data and
known case and admission data such as assignment to the departmental organizational unit or planned services are entered. These time-independent entries
are given a priority status. Based on this status, such a waiting list entry can be
changed to a planned or actual admission.

Prioritized Entries in
Waiting Lists

This option of entering movements in planning enables the admission personnel

to enter data outside periods of maximum work load. When the movement actually occurs, the amount of data to be entered and work load peaks are reduced.

Easing the Workload of

Admission Personnel

In addition to scheduling all movements, you can create a prioritized waiting list.

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Patient Management

Variable Case Information

In addition to mandatory data which describes a case and is maintained in the
IS-H operational functions, each hospital can define and document additional
attributes as additional information.

Hospital-Specific
Additional Information

This information covers the following areas:

q

Case-to-person assignment
Persons may be assigned to a case with user-definable functions.
Examples: Attending nurse, attending physical therapist

Case-to-case-assignment
Cases can be assigned to each other with freely definable functions.
Examples: Organ donor/organ recipient, parents/child

Case classification
You have the option to define and maintain user-definable case attributes
including authorized characteristics.
Examples: Treatment type: somatic/psychiatric, diet:
Regular/body building/bland/diet.

Hospital-specific additional information can be maintained in addition to mandatory case

data.

Nursing Station Management

Nursing Station Management offers an approach to processing patient-related
data which is different from the patient management functions described so far.
It looks at the nursing station and the patients assigned to this station. Nursing
Station Management provides the IS-H functions required on the nursing stations in a user-friendly environment which takes into consideration the workplace requirements on the nursing stations. The general IS-H menus with all ISH functions are also available on the nursing stations.

Nursing Station-Specific User

Interface

An important administrative function of Nursing Station Management is bed

assignment planning, i.e. the planning and administration of bed assignments
within organizational units supporting beds. The room and bed listing serves as
a starting point for bed assignment planning. It offers a summary of bed assignments for each organizational unit at any level of the hierarchy at a user-defined
time. This summary shows the accumulated bed assignment numbers for this
organizational unit. The display includes information such as the number of free
bed locations, assignable bed locations, planned beds, etc. In addition, the arrivals and departures planned for a definable period may be displayed. Starting
with the selected organizational unit, this information can be called up in detail
for all lower-level organizational units down to the lowest level, the units supporting beds (see Fig. 5-10).

Bed Assignment Planning

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All IS-H Functions Available

Room and Bed Listing

Patient Management

Fig. 5-10: Summarized Room and Bed Listing

The nursing station overview illustrates the beds assigned to patients at a selectable time for an organizational unit supporting beds. The screen shows the assignment of patients to rooms and bed locations and can be displayed as a list or
in graphic form. From the nursing station overview, further functions may be performed such as:
q Processing patient, case, or movement data for a patient
q Maintaining diagnoses or nursing categories
q Requesting medical records
q Entering services
q Entering surgical procedures
q Generating work organizers

Fig. 5-11: Graphical Nursing Station Overview

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Patient Management

Planning in the Nursing

Station Overview

Replacing the Patient

Traffic List
Access to Central
Patient Database
Additional Nursing
Station Functions

Actual planning is another important function of the nursing station overview.

The screen displays the assignment of each bed location during a selectable planning period and a list of all patients assigned to the nursing station, but not to a
specific bed (arrival list), and all patients transferred or discharged during this
period (departure list). Special planning functions such as assigning a patient to a
bed location within the nursing station, the swapping of beds among patients or
the transfer or discharge of a patient may be performed so that the nursing staff
can enter patient movements into the system very easily. A patient traffic list for
the nursing station linked to IS-H is not necessary.
In addition to the functions described in the nursing station overview, Nursing
Station Management provides all additional important functions required on the
nursing station. Since the nursing station has direct access to the central IS-H database, the latest data is always available.
Additional Nursing Station Management functions include:
q Information functions, such as listings of standard, quick, or emergency admissions, outpatient visits, waiting lists, etc.
q Patient admission
q Admission of newborns and companions
q Managing diagnoses and nursing categories for the patients on the nursing
station
q Requesting medication and material from the central warehouse

Outpatient Department Management

Outpatient Dept Mgmt
as User Interface
Visit Planning

Outpatient Department Management provides a user interface similar to that of

Nursing Station Management. It allows you to plan outpatient department visits
and offers those IS-H functions which are required in outpatient departments.
q Visit Planning

Phys./Rooms as Resources
Available Time Slots for
Different Planning Types

On-Screen Appointment
Schedules
Visit Status Management
Provisional Appointments

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Resources considered relevant for outpatient visits are the attending physicians and the available treatment rooms. Available time slots are stored on a
daily and weekly basis for these resources and for the outpatient departments
themselves. The planning types are user-definable, such as initial visits, follow-up examination, etc. For instance, it is possible to specify that follow-up
visits by a specific physician may only be scheduled at pre-defined times on
selected weekdays. Based on these available time slots, on-screen appointment schedules are generated for the resources which need to be planned. The
patient visits are entered into these appointment schedules and are assigned
to the respective physician or treatment room. New cases and/or patients can
be scheduled and admitted at the same time. A detailed visit status management function allows you to easily control patient treatment including visit
planning, making the appointment, and actual treatment. You may also schedule an appointment without having to create a patient master record or case.

Patient Management

Fig. 5-12 Appointment Schedule

q Additional outpatient department functions:

Outpatient Department Management provides all IS-H functions required in
an outpatient department, such as:

All IS-H Functions are

Available

m Patient Master Data

m Service entry
m Medical documentation (diagnoses, etc.)
m Administration of certificates
m Administration of medical records
m Printing of forms

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Patient Management

Forms Management and Work Organizers

Standard Forms
Forms Editor
Bar Codes

The standard system includes a number of forms such as patient status reports,
patient labels, admitting release forms for patient and insurance provider, etc. You
can customize these forms using a forms editor or define additional forms. It is
also possible to define any type of bar code for labels. Bar codes and labels are
generated automatically after certain functions have been performed (e.g. during
patient admission) or upon request. Tables can be set up which specify where the
item will be printed, how many copies will be printed, etc.

Medical/Nursing Documentation
Nursing acuities
Nursing Acuities

To determine the professional staff needed for adult and pediatric patient care in
relation to nursing acuities the system supports the following processes:

Nursing Effort per

Nursing Acuity

q Definition of nursing acuity for determining the nursing effort as well as the
assignment of nursing care minutes per day. Storing minimum requirements
for patient care and case weights to determine the staff required for adult and
pediatric patient care.

Assignment to Nursing Acuity

q Assignment of inpatient cases to nursing acuity.

Case-related nursing acuity management by selecting a case (case view) or
managing the nursing acuity for all patients of a nursing station (nursing organizational unit) at a certain key date (nursing station view of Nursing Station Management).

Reports

q A comprehensive reporting system is offered to ensure a complete database

for determining staff requirements and analyzing data for internal purposes.

The system supports the assignment of patients to nursing acuities and the determination of staff requirements based on this assignment.

Diagnoses
Diagnoses for Each Case and
Department Stay
Diagnosis Types

IS-H manages diagnoses for each case and departmental stay and makes them
available both for medical documentation and for statistical purposes.
The system distinguishes between two types of diagnoses:
q Admission or transfer diagnoses
q Treatment diagnoses made while the patient was treated in the medical facility.

Classification of Diagnoses

Treatment diagnoses are definable as:

q Admission diagnosis
q Surgery diagnosis

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Patient Management

q Discharge diagnosis
q Departmental main diagnosis
q Hospital main diagnosis
Multiple diagnoses can be maintained for each case or departmental stay. Each
diagnosis is entered as free text or as a code using a combination of two diagnosis
code catalogs (e.g. ICD-9, ICD-10). The diagnosis code catalogs are user-definable. Available input facilities take the form of the text search in diagnosis code
catalogs, hit lists, hierarchy search in hierarchic catalogs, and automatic conversion using connectable special systems.

Multiple Diagnoses
Parallel Coding
Possible Entry Facilities

Fig. 5-13: Diagnoses

The diagnosis is entered as part of the work process so that you may edit the
information when processing admissions, transfers and discharges. As an alternative, diagnoses are processed separately from movements, for instance, as postdischarge documentation. The diagnoses can be maintained on a case-related basis for a specific case or collectively, for instance for all cases of an organizational
unit.
Various reports (for example, a list of all cases without a discharge diagnosis)
support you in maintaining a complete database.

Post-Discharge
Documentation
Reports as Work Tools

IS-H allows you to enter multiple case- and department-related diagnoses which can be
coded based on different catalogs and assigned to several classifications.

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Surgery
Legally Mandated Surgery
Documentation
ICPM Coding
Surgery Diagnosis

IS-H offers a surgery documentation function which complies with legal requirements. For each surgery performed, you can enter administrative data such as
time of surgery, organizational unit in charge, operating surgeon, operating room,
etc. and the services performed (in the service catalog), surgery codes according to
the ICPM catalog, and a surgery diagnosis for each ICPM code.

IS-H supports surgery documentation which is legally mandated for determining charges.

Risk Factors
Risk Factors at Patient Level

While the medical/nursing information described above is maintained on a case

level, risk factors are maintained on a patient level and apply to all cases.

Hospital-Specific Catalog
Maintenance

The possible risk factors are stored in a catalog which is maintained based on
specific hospital needs. Possible factors are:
q Allergies to antibiotics
q Hypertension
q Diabetes

Risk factors are documented at patient level.

Medical Record Administration

Different Record
Creation Strategies

Because of the many organizational models in the hospital with respect to filing,
the file system, and archive management, individual medical records for each patient are created with varying frequency and in varying numbers. The system
therefore supports the following record creation strategies:
q Creation of a new medical record upon initial admission to the hospital; no
record created upon re-admission
q Creation of a new medical record upon every admission to the hospital
q Creation of a medical record per department
q Creation of a medical record per case and department
q Creation of a medical record per patient movement (e.g. transfer)

Medical Record List

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The system manages data regarding the existence, location, and movements of a
medical record. It also contains information on who borrowed a record, when it
was borrowed, and why.

Patient Management

Medical Record Administration provides the following functions:

Processing Functions

q Display, input, and change of medical records

q Information on:
m newly created medical records
m lists of patients admitted after the date you specify, nursing station location, whether medical records exist for the patient, and the location of said
records
q Create reminders for borrowed medical records
q Administration of borrowed medical records (request, lend, transfer, return
medical records)
q Evaluations
m current medical records (for example, to obtain an overview of archive
occupancy and reorganize the archives where necessary)
m borrowed medical records; selection criteria include:
- medical records for which a reminder was created
- borrowed records by borrower
- borrowed records by date, etc.
m externally-stored old medical records
A detailed data security concept ensures that only authorized users have access to
medical records.

Authorized Access

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