Data is only as good as the use you can make of it
medudoc provides everything it captures and generates via interfaces – the medical history as FHIR QuestionnaireResponse or PDF, the premedication record as PDF, patient education and consent as PDF/A. For the hospital information system (HIS), patient data management system (PDMS) and archive system.
- Medical history
- FHIR QuestionnaireResponse
- Premedication record
- Patient education and consent
- PDF/A with consent trail and medical history
- # to HIS, PDMS and archive system
Outputs
What medudoc hands over – and where to
Every result of the workflow is available in a format your systems can process. Patient master data and planned procedures come from the HIS via FHIR, and the results go back.
| Data | Format | Destination |
|---|---|---|
| Medical history | HIS, PDMS, archive system | |
| Premedication record | HIS, PDMS, ward | |
| Patient education and consent | HIS, archive system | |
| Consent trail and audit log | Archive system, internal audit | |
| Signed documents for patients | Patient portal, for viewing and downloading |
Evidence
Fully documented, retrievable at any time
In the event of a dispute, what counts is what can be proven. medudoc documents the entire patient education process and combines it with the document.
Consent trail
Complete documentation of the patient education process: when the sheet was opened, which video sections were watched and when it was signed – with timestamps.
Audit log
Complete and exportable, for internal audit and quality management.
One PDF/A per consent
Consent sheet, consent trail and medical history in one audit-proof document.
Ten years of retention at medudoc
medudoc retains the documents for ten years – in line with the retention period for patient records under Section 630f(3) of the German Civil Code (BGB) and in addition to the handover to your archive system.
Standards
Open formats instead of an isolated solution
medudoc relies on established standards so that your data remains usable in every downstream system.
- transfer of structured data to HIS and PDMS
- HL7 FHIR
- normalised medical information
- SNOMED CT
- audit-proof long-term archiving
- PDF/A
- Platform API and Partner API for other systems
- API
- Details on FHIR, Platform API and Partner API can be found on the Integrations page.
- medudoc is ISO/IEC 27001:2022 certified; the evidence is available in the Trust Center at trust.medudoc.com.
More on the platform
- InterfacesHL7 FHIR, Platform API and Partner API for HIS, PMS and partner systems.Learn more
- SecurityISO/IEC 27001:2022 certified, BSI C5 Type 2 attested, data processing in Germany.Learn more
- Digital consent sheetPatient-specific consent sheet with electronic signature.Learn more
- Premedication & handoverPremedication with fully prepared cases, followed by handover to the HIS via FHIR.Learn more
How does the data flow into your HIS?
In a meeting with your IT team, we show you formats, interfaces and the handover to your archive system.