Although the electronic medical record (EMR) has been applied extensively, the sharing and exchange of medical records between hospitals are still very difficult because of the variety of the size of hospitals and the absence of a standard form for clinical records. As the network technology is developed fast, constructing standardized forms and modules for medical information exchange becomes a necessary beside the numerous services provided by any hospitals.

For the purpose of the development of the medical informatics in Taiwan, the Department of Health Executive Yuan initiated a project in 2004 for establishing a standard template of medical record and unified medical vocabulary. The project also put forward the preferential order of carrying out for which levels that the EMR standard template.

In this research, we used the idea of Delphi Method to assemble an expert decision-working group, 11 experts in the domain of nursing care were enrolled. The experts were from different clinical agencies including medical centers and regional hospitals. They had one meeting every month from November 2004 to March 2005. We analyzed 869 nursing data fields, defined 33 record modules, and created six forms (or templates) including Vital Signs, Nursing Assessment, Nursing Intervention, Nursing Diagnosis, Care Plan, and Nursing Record of electronic nursing care.

The standard templates have been used as the carrier of the nursing information exchange. XML structured documents were created to build a web-based EMR prototype system. After that, HTML-based documents were transformed to support the functions of data querying and downloading from the patients and clinical institutes using the interface of Web browser.