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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
v1.1 – Service Requirement & Specifications
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
v1.1 – Service Requirement & Specifications
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
v1.1 – Service Requirement & Specifications
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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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:
Element Type Constraint NULL? Business Rules
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
v1.1 – Service Requirement & Specifications
Element Type Constraint NULL? Business Rules
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
Element Type Constraint NULL? Business Rules
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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2.2.2.2.1. CaseInfoStructure:
Element Type Constraint NULL? Business Rules
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
v1.1 – Service Requirement & Specifications
Element Type Constraint NULL? Business Rules
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
String Min length is 1Max length is 500
Yes
Service ServiceStructure (Array of ServiceStructure)
Min occurs is 0 Yes
Comment CommentStructure (Array of CommentStructure)
Min occurs is 0 Yes
Admission AdmissionStructure
Yes
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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2.2.2.2.1.1. IllnessCode
Element Type Constraint NULL? Business Rules
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
Element Type Constraint NULL? Business Rules
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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2.2.2.2.1.3. OpticalReadingStructure
Element Type Constraint NULL? Business Rules
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
Element Type Constraint NULL? Business Rules
InvestigationType String Min length is 1Max length is 50
No
InvestigationCode String Min length is 1Max length is 50
No
InvestigationDescription
String Min length is 1Max length is 500
No
InvestigationDate Date No According to YEFI Standards.
Observation ObservationStructure (Array of ObservationStructure)
Yes
2.2.2.2.1.4.1. ObservationStructure
Element Type Constraint NULL? Business Rules
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
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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Element Type Constraint NULL? Business Rules
ObservationComment String Min length is 1Max length is 500
Yes
2.2.2.2.1.5. ServiceStructure
Element Type Constraint NULL? Business Rules
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
Element Type Constraint NULL? Business Rules
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,
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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Element Type Constraint NULL? Business Rules
STAT, QHS values. The default value is “QD”
DurationOfTreatment Duration No
2.2.2.2.1.6. CommentStructure
Element Type Constraint NULL? Business Rules
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
Element Type Constraint NULL? Business Rules
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
Element Type Constraint NULL? Business Rules
ActualLengthOfStay Duration YesDischargeDate DateTime Yes
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2.2.2.3. ConditionStructure
Element Type Constraint NULL? Business Rules
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
String Min length is 1Max length is 1000
No
ConditionComment
String Min length is 1Max length is 1000
No
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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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.
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e-Government Program (Yesser)CHS -Hospital Patient Record Service-Requirements and Specifcations
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4. ReferencesList all references here
Ref 1 Ref 2
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