数字化病案库的建立与应用  

Digital Library Development and Application in Medical Records

作　　者：陈俐[1] 戴子卿[1] 冯洁[1] 邹郢[1] 黄萍[1] 荣霞[1] 翁盛鑫[2] 黄影[2] 罗晶[2] 俞朝晖[3] 于涛[3] 

机构地区：[1]中国人民解放军海军总医院病案管理科,北京100048 [2]中国人民解放军海军总医院计算机中心,北京100048 [3]中国印刷科学技术研究所,北京100036

出　　处：《医疗卫生装备》2011年第4期44-48,共5页Chinese Medical Equipment Journal

摘　　要：目的:实现医院医务人员在办公室阅读病案库内病案,方便各类人员使用医学病案资料。方法:通过数码照相机和电子扫描仪对病案原件内容翻拍和扫描,使医院现存的纸质病案文件转换为具有电子文件性能的数字化文档,再结合医院临床实际编制的软件,实时地将病案库数据与翻拍和扫描的病案内容相融合,呈现原貌的、实质的病案。结果:医务人员可随时通过编制软件阅读医院病案库存病案,放大医院病案为医、教、研服务的功能。结论:方便了临床医务人员使用病案,提高了医院病案的利用效率,减轻病案管理人员的工作压力,是一种实用和有效的病案管理方式。Objective To realize the medical staff can read the medical records from medical records database in office,and make it easy for all the personnel to use the medical records.Methods The original contents of medical records were remade and scanned by digital cameras and electronic scanners so that the current paper-based medical records converted into electronic files with the performance of digital documents.With the combination of software based on the clinical practice in the hospital,the data in medical records database was integrated with the remade and scanned medical records in real time to present the original and essential medical records.Results The medical staff could read the medical records inventory from the medical records database at any time by the software,thus the functions of medical records service for medicine,teaching and research were enlarged.Conclusion The establishment of the digital medical records database makes it convenient for the medical staff to use the medical records,improves utilization efficiency of the hospital medical records,and reduces the pressure of case management staff,which is a practical and effective case management approach.

关 键 词：病案 管理 软件系统 数字化 

分 类 号：TP311.13[自动化与计算机技术—计算机软件与理论] R197.323[自动化与计算机技术—计算机科学与技术]