神经内科急诊电子病历的设计与实现  

Design and Implementation of a Neurology Emergency Electronic Medical Record System

作　　者：郝梅[1] 廖晓凌[1] 廉裕辉 王韬[1] 

机构地区：[1]首都医科大学附属北京天坛医院信息中心,北京100050 [2]沈阳东软软件股份有限公司,辽宁沈阳110179

出　　处：《中国医疗设备》2009年第3期28-31,共4页China Medical Devices

基　　金：国家科技支撑计划资助项目(2006BA101A11);首都医学发展科研基金项目(基金编号:2005-2023)。

摘　　要：目的设计与开发神经内科急诊电子病历,以实现对神经内科急诊病人信息的采集、加工、存储和传输。方法以Oracle为后台数据库、Powerbuilder 6.5为前台开发工具,通过建立神经内科结构化病历,实现神经内科电子病历系统。结果该病历系统已在神经内科急诊使用,系统运行良好,达到了存储和传输病人信息、快速查询的目的。结论该系统能对医疗过程实施科学管理和智能化控制,有效提高临床医疗质量,提高医生书写病历的效率与质量,积累大量病历资料,方便临床、科研工作,为将来实现决策支持、规范和辅助治疗打下基础。Objective To design and develop a neurology emergency electronic medical record system, so as to gather, process, store and transmit the information of neurology emergency patients. Methods The neurology emergency electronic medical record system was realized based on the structured neurology emergency medical records, Oracle serve as the back-end database, along with the front- end interface code in Powerbuilder. Results The system has been used in neurology emergency department, with the practice of using. It indicated that this system runs well. This system could achieve the goal of storage and transmit patient＇ s information, and have quick seeking. Conclusion The system could help the doctors to improve the efficiency and quality of medical records, accumulate plenty of medical materials, provide the convenience for the work of clinic and research, and lay a basis for the implementation of decisionsupport, standardization and assistant therapy.

关 键 词：神经内科急诊 电子病历 决策支持 HIS 

分 类 号：R197.324[医药卫生—卫生事业管理]