基于电子病案信息制定临床路径的方法  

作　　者：兰小筠[1] 程趁娜[1] 徐连杰[1] 何四维[1] 

机构地区：[1]中南大学湘雅医学院医药信息系,长沙市410013

出　　处：《中国卫生信息管理杂志》2011年第3期75-79,共5页Chinese Journal of Health Informatics and Management

摘　　要：目的利用医院电子病案信息制定临床路径,并提出一种通用模式。方法对所选病种的所有病例进行住院流程重组,按并发症类型和年龄分组,分析各组的住院流程,得出该病种的合理住院日,利用帕累托法确定关键项目和必要时项目,并计算各个项目的开始时间和结束时间,与国内外同病种临床路径进行比较,做出相应的调整,得出临床路径。结果得出所选病种的临床路径表,并据此提出基于电子病案信息制定临床路径的通用模式。结论利用电子病案信息制定临床路径的方法有一定的优势,克服了以往制定临床路径过程中存在的主观性,并充分考虑了医院自身的医疗卫生资源,使得临床路径的制定更为科学、合理,指导性更强。Objective By analysing electronic medical records and reengineering hospitalized process,the purpose is to formulate a suitable medical pathway for hospital.Meanwhile,try to put forward a general pattern of formulating medical pathway by using electronic medical record.Methods After reorganizing the hospitalized process,the research objects were separated into different groups according to the type of complication and age.By analysing the hospitalized process of each group,reach the resonable average time in hospital.Using pareto law,key items and essential items were determined.Meanwhile,the start and end time of each item were calculated.Taking the treatment guidelines of paitents with cholelithiasis for reference,part of items were discussed.Finally,comparing to other medical pathways with the same disease both at home and abroad,the proper clinical pathway can be made out.Results Formulate a suitable medical pathway for hospital,put forward a general pattern of formulating medical pathway by using electronic medical record.Conclusions The method of formulating clinical pathway by using electronic medical record information is discussed.This method overcomes the subjectivity existing in the process of the past clinical pathways and shows a certain advantages.It makes the formulation of clinical pathway more scientific and reasonable by making full consideration of their own medical resources of hospitals.

关 键 词：临床路径 电子病案 住院流程重组 帕累托法 

分 类 号：R197.3[医药卫生—卫生事业管理]