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e-Government Program (Yesser)

CHS -Hospital Patient RecordService-Requirements and

Specifcations v1.1Service Requirement &

Specifications

e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations

v1.1 – Service Requirement & Specifications

Document Description

Document Title Hospital Patient Record Service – Service Specifications Document version 1.0Document Status Draft

Versioning Version Date Description of changes made1.0 23/01/2009 Document template creation1.1 24/02/13 First Draft of the document.

Document ValidationVersion Author Review by Date Status

1.0 Mohammed A. Al-Barrak Mohammed Yassen 24/02/13

Confidential e-Government Program (Yesser)This document (either in whole or in part) cannot be modified or

reproduced without the prior written permission of the e-Government Program (Yesser) / 16



Table of Contents

1. Introduction.................................................................................................................... 41.1. Overview................................................................................................................... 41.2. Definitions, Acronyms, and Abbreviations................................................................41.3. Assumptions............................................................................................................. 4

2. Service Specification..................................................................................................... 52.1. Hospital Patient Record Service....................................................................................5

2.1.1. Operations............................................................................................................................................52.2. Business Object Definition........................................................................................6

2.2.1. Input:.....................................................................................................................................................62.2.2. Output:..................................................................................................................................................62.2.2.1. DemographicsStructure........................................................................................................................62.2.2.2. EncounterStructure...............................................................................................................................72.2.2.2.1. CaseInfoStructure:............................................................................................................................82.2.2.2.1.1. IllnessCode....................................................................................................................................102.2.2.2.1.2. DiagnosisStructure.........................................................................................................................102.2.2.2.1.3. OpticalReadingStructure................................................................................................................112.2.2.2.1.4. InvestigationStructure....................................................................................................................112.2.2.2.1.4.1. ObservationStructure..................................................................................................................112.2.2.2.1.5. ServiceStructure.............................................................................................................................122.2.2.2.1.5.1. DrugUseStructure.......................................................................................................................122.2.2.2.1.6. CommentStructure.........................................................................................................................132.2.2.2.1.7. AdmissionStructure........................................................................................................................132.2.2.2.1.7.1. DischargeStructure.....................................................................................................................132.2.2.3. ConditionStructure..............................................................................................................................14

3. Non-Functional Requirements...................................................................................153.1. Performance........................................................................................................... 153.2. Throughput............................................................................................................. 153.3. Security and Access control...................................................................................153.4. Availability............................................................................................................... 153.5. Fault Tolerance....................................................................................................... 15

4. References................................................................................................................... 16





1. Introduction1.1. OverviewCouncil of Health Services (CHS) is a leading government agency that is responsible to develop regulations that ensure proper coordination and integration among the various health agencies in the Kingdom. They are also responsible to ensure that these health agencies adhere to provide high quality health services in smooth and safe manner. Also, it works with the health agencies and relevant sectors to ensure proper implementation of national programs that develop and enhance the health sector.

The aim of the electronic medical record (EMR) project is to provide a service that facilitates the integration between the government hospitals in order to share the patients’ medical records, and enables the doctors to see the patient medical history from all government hospitals to provide accurate decisions

1.2. Definitions, Acronyms, and AbbreviationsEMR: electronic medical record.CHS: Council of Health Services.

1.3. Assumptions The providers and the consumers for EMR service are the government and semi

government hospitals in Riyadh, and they are:

1. King Faisal specialist hospital

2. King Fahd Medical City

3. Security Forces Hospital.

4. National Guard Health Affairs

5. Riyadh Military Hospital

6. King Khalid University Hospital





2. Service Specification2.1. Hospital Patient Record Service

HospitalPatientRecord

Description The purpose of this service is to retrieve medical records details that corresponding to a certain patient from all of the integrated health agencies. This service considers the National/Iqama Id and birth data of the patient as an identifier. The retrieval information is all about condition information and medical history of the patient along with their demographic details.

2.1.1.Operations

1. Get Patient Record

getPatientRecord

Description The purpose of this operation is to retrieve medical records details that corresponding to a certain patient from all of the integrated health agencies. This operation uses the National/Iqama Id and birth data of the patient as an input to conduct the inquiry and retrieve the information.

Input Patient Id: Representing national id for citizens or Iqama id for expatriates.

Date of birth Representing date of birth for the patient.Output Demographics information such as: Patient name, Nationality... etc.

Conditions information such as: Type, Date, Description... etc.Medical History such as: Type, Date, Department... etc.For more details, refer to business objects section.

Business Rules “Get Citizen Profile” MOI web service must be used if the user is citizen, and pass National ID and Date of Birth as input parameters.

“Get Resident Profile” MOI web service must be used if the user is resident, and pass IQAMA Number and Expiration Date as input parameters.

Special Notes

Errors Error Code Description001-000001 No Record Found001-000002 Invalid input





getPatientRecord500-000001 System error.

2.2. Business Object Definition2.2.1. Input:

Element Type Constraint NULL? Business Rules

ID Number Length is 10 digits No According to YEFI Standards.

DOB Date No According to YEFI Standards.

2.2.2.Output:


MRN String Min length 1Max Length 50

No

Demographics DemographicsStructure No

MedicalHistory EncounterStructure (Array of EncounterStructure).

Min occurs is 0 Yes

SpecialConditions ConditionStructure

(Array of ConditionStructure)

Min occurs is 0 Yes

Comment String Min length 1Max Length 500

2.2.2.1. DemographicsStructureElement Type Constraint NULL? Business Rules

DOB Date No According to YEFI Standards.

Address AddressStructure No According to YEFI






Standards.

EmegencyContact\ FullName

PersonNameDetailsStructure

No According to YEFI Standards.

EmegencyContact\ Contact

ContactDetailsStructure No According to YEFI Standards.

FirstName String Min length 1Max Length 50

No

MiddleName String Min length 1Max Length 50

No

LastName String Min length 1Max Length 50

No

FullName String Min length 1Max Length 150

No

Id Number Length is 10 digits

No According to YEFI Standards.

Nationality String No - ISO code is followed.

- YEFI Standards

2.2.2.2. EncounterStructure


EncounterType String Min length is 1Max length is 100

No

EncounterDate Date No According to YEFI Standards.

DepartmentCodeType

String Enum values from 1 to 53 that represent departments in hospitals

No

CaseInfo CaseInfoStructure

No





2.2.2.2.1. CaseInfoStructure:


CaseType String Enum of INPATIENT, OUTPATIENT, DENTAL, DELIVERY, OPTICAL values

No

PhysicianName String No

PhysicianID String No

PhysicianCategoryType

String Enum of ENERAL PRACTICE, SPECIALIST, CONSULTANT values.

BloodPressure String Min length is 1Max length is 100

Yes The field should only accept values comply with the following expression: “/d{2,3}//d{2,3}”For example: "120/80"

Temperature Decimal Length is 3.0Min value is 32.0Max value is 42.0

Yes

Pulse Decimal Min value is 0Max value is 300

Yes

RespRate Decimal Min value is 0Max value is 200

Yes

Weight Decimal Min value is 0.00Max value is 300.00

No

LMP Date Yes/No Required if { caseType = Delivery}

Not Required if { case type = all other types}

IllnessCategory (Array of IllnessCode)

Min occurs is 0

Max occurs is 8

Yes






IllnessDuration Duration No P(years)Y(months)M(days)DT(hours)H(minutes)M(seconds)S

Diagnosis DiagnosisStructure (Array of DiagnosisStructure)

Min occurs is 1 No

Optics OpticalReadingStructure

Min occurs is 2

Max occurs is 10

Yes

Investigation InvestigationStructure (Array of InvestigationStructure)

Min occurs is 0 Yes

ChiefComplaintSymptoms

String Min length is 1Max length is 500

Yes

SignicantSigns String Min length is 1Max length is 50

Yes

PossibleLineOfTreatment


Yes

Service ServiceStructure (Array of ServiceStructure)

Min occurs is 0 Yes

Comment CommentStructure (Array of CommentStructure)

Min occurs is 0 Yes

Admission AdmissionStructure

Yes





2.2.2.2.1.1. IllnessCode


IllnessCode String Enum of AMBULANCE, DIALYSIS, CHECKUP, CHRONIC, CIRCUMCISION, CLEANING, CONGENITAL, INFERTILITY, MATERNITY COMPLICATIONS, PREEXISTING, NA, ORTHODONTICS, PREGNANCY, PSYCHIATRY, RTA, SPORTS, VACCINATION, WRA values

No

2.2.2.2.1.2. DiagnosisStructure


DiagnosisNumber Long Yes/No Required IF {diagnosis already been submitted and provider wishes to modify of deletel}

Not Required IF { diagnosis is new and provider wishes to add it }

DiagnosisCode String Min length is 1Max length is 50

No

DiagnosisType String Enum of PRINCIPAL, SCONDARY, ADMITTING, DISCHARGE, CAUSEOFDEATH, PROVISIONAL values.

No

DiagnosisDescription

String Min Length is 1Max Length is 500

Yes





2.2.2.2.1.3. OpticalReadingStructure


Geometry String Enum of SPHERE, SYLINDER, AXIS values.

No

Side String Enum of OS, OD values.

No

focus String Enum of NEAR, DISTANCE values.

No

2.2.2.2.1.4. InvestigationStructure


InvestigationType String Min length is 1Max length is 50

No

InvestigationCode String Min length is 1Max length is 50

No

InvestigationDescription


No

InvestigationDate Date No According to YEFI Standards.

Observation ObservationStructure (Array of ObservationStructure)

Yes

2.2.2.2.1.4.1. ObservationStructure


ObservationCode String Min length is 1Max length is 50

No

ObservationDescription String Min length is 1Max length is 500

No

ObservationValue decimal Min length is 1Max length is 50

No

ObservationUnit String Min length is 1Max length is 50

No






ObservationComment String Min length is 1Max length is 500

Yes

2.2.2.2.1.5. ServiceStructure


ServiceNumber Long Yes

ServiceDate Date No According to YEFI Standards.

ServiceType String Enum of LABORATORY, MEDICATION, RADIOLOGY, CONSULTATION, PROCEDURE, HOSPITLIZATION, DENTAL, SUPPLY values

Yes

ServiceCode String Min length is 1Max length is 50

No

ServiceDescription String Min length is 1Max length is 500

Yes

ToothNumber String Enum of 1 to 32 and A toT values

Yes

RequestedQuantity Decimal No

DrugUse DrugUseStructure Yes

2.2.2.2.1.5.1. DrugUseStructure


Dosage Decimal Yes This element has Unit attribute and it return Enum of GM, MG, MCG, CC, ML, TSP, TBSP, GTT, TAB, CAP valuesDefault is “TAB”

DoseTimes Integer Min length is 1Max length is 100

No This element has an qualifier attribute and it return Enum of QD, QH, PC, AC, PRN, QOD,






STAT, QHS values. The default value is “QD”

DurationOfTreatment Duration No

2.2.2.2.1.6. CommentStructure


CommentDate Date No According to YEFI Standards.

CommentText String Min length is 1Max length is 500

No

CommentType String Enum of PAYER, PROVIDER values

No

2.2.2.2.1.7. AdmissionStructure


AdmissionDate Date No According to YEFI Standards.

AdmissionType String Enum of ELECTIVE, EMERGENCY, REFERRAL values.

No

EstimatedLengthOfStay Duration NoRoomNumber Integer Min length is 1

Max length is 1000

No

Discharge DischargeStructure

Yes

2.2.2.2.1.7.1. DischargeStructure


ActualLengthOfStay Duration YesDischargeDate DateTime Yes





2.2.2.3. ConditionStructure


ConditionType String Min length is 1Max length is 100

No

ConditionDate Date No According to YEFI Standards.

ConditionCode String Min length is 1Max length is 50

No

ConditionDescription


No

ConditionComment


No





3. Non-Functional Requirements3.1. PerformanceMaximum response time of 600ms.

3.2. Throughput Supported number of 50 transactions per second with response time less than 600ms

3.3. Security and Access controlList here any special security requirements the service design must adhere to, including access control limitation, encryption of data, etc.

3.4. AvailabilityList the availability requirements of the service

3.5. Fault ToleranceNon-transaction service must have 99.5% success rate.





4. ReferencesList all references here

Ref 1 Ref 2



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