OCQMS - Clinical Documentation

The interdisciplinary medical patient records help physicians and healthcare professionals with medical documentation over the entire course of treatment.
Structured documentation processes in electronic health records result in improved data quality and thereby increase patient safety.

OCQMS reports are structured according to the SOAP (subjective well-being, objective findings, assessment, treatment plan) documentation method.

Medical reports (discharge summaries)

Medical reports should be provided as soon as possible to all involved parties (physicians, healthcare professionals, patients). Already captured content (history, findings, diagnoses, procedures, etc.) is automatically included in the discharge letter and can be expanded and changed at any time until completion.

If all findings are not available (e.g. pending laboratory results), provisional reports can be generated. OCQMS shows users a list of open reports at any time. Authorized doctors can compose provisional reports and complete rounds.

• Predefined text modules
• Discharge letters, letters for transfers
• Medical certificates
• Coding of diagnoses
• Prescriptions, formulas

The generated reports can be transmitted via an interface to the long-term archive, where they are stored safely and in compliance with the law.

Quality Management / Benchmarking / Research

Clinical raw data - not indicators collected via surveys - are used as the data basis for quality management. Metrics for quality assurance are available in real time.

An example of the presentation and visualization of data is the plot of patients in ascending order by disease activity (DAS score). Hereby patients with high disease activity can be detected at a glance. Each data point has a direct link to the patient so that further investigations can be conducted.

The structured data can be used directly for research purposes in aggregated, anonymous form.

Our vision: Bridging the gap between medical practice and medical research.

Data Security (Encryption)

OCQMS offers two-factor authentication with YubiKey. YubiKey combines bank-grade security with usability.

All information transferred between your browser and the server is protected with 256-bit SSL encryption.

Particularly sensitive personal information is encrypted in the database using AES (Advanced Encryption Standard).