| Abstract text: |
Ensuring effective informational management in the practice of occupational medicine requires the employment of Electronic Health Record. Electronic Health Record structuring must take into account the general minimum requirements referring to its functions, in compliance with national legislation. Romanian law specifies both mandatory data fields that should be provided for individual medical records and the tasks of each actor involved in developing regular medical examination, as well as data classification standards referring to occupations, economic activities, job related noxious agents, diagnosis and medical procedures. Employment of adequate standards for data recording and processing that are relevant for the informational flow of all the structures involved in health and security promotion of workplaces imposes adequate structuring of the nucleus of any medical computer-based information system represented by EHR. EHR occupational medicine structure should provide support both for associated processes involved in the medical act as well as for activity- and requirement-specific processes in the particular interrelationship between the professional medicine specialist and the employee. Based on these considerations, the current paper proposes an Electronic Health Record model and a modality of assessment for application in occupational medicine. The study of these requirements led to an EHR model structure. The type and format of the given data in order to ensure interoperability for future medical filing systems, starting from information circuits specific for the medical office, led to a model of electronic health file. Starting from the necessity of its implementation in medical practice, ways of its evaluation and acceptance in current medical practice were outlined: questionnaires, discussion forums that were addressed to the main actors involved: the worker, physician and employer. |
