数字化病案库建立的工作流程  

The Work Procedure of Setting up Digitalized Medical Records Database

作　　者：陈俐[1] 黄萍[1] 冯洁[1] 荣霞[1] 邹郢[1] 翁盛鑫[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 [2]中国人民解放军海军总医院计算机中心 [3]中国印刷科学技术研究所

出　　处：《中国病案》2011年第7期34-36,共3页Chinese Medical Record

摘　　要：目的介绍"数字化病案库"软件的工作流程,使得病案管理更加有序、更加准确、更加方便医务人员使用。方法以数字化病案系统为中心,挂接"军卫一号系统"、"病案编目系统"和"老病案管理软件",获取完整、准确的病案数据,建立统一的数据池,通过数据挖掘和数据采集等技术,对病案各项数据进行采集、提取;病案页面扫描及图片存储;病案数据与图片数据索引编排等处理。结果实现病案数据的统一管理、网络传输、共享应用,并对病案数据进行优化、整理、挑错、提高数据的准确度。结论 "数字化病案库"的出现是病案管理工作质的飞跃,是医疗质量、病案质量与临床医疗工作有效结合的体现,建立"数字化病案库"工作中的各项流程至关重要。Objectives An introduction to work procedure of digitalized medical record database software makes medical records management more orderly,more correct and more access to medical staffs.Methods Focus on digitalized medical records system while mounting No.1 military medical project,medical records catalogue system and old medical records management software to access to complete and correct data of medical record and to set up unite data pool.Through data digging and data collection technologies,we have data of medical records collection and extract;pages of medical records scan and photograph storage;data of medical records and photograph data index and arrangement.Results It is realized that unite management,network transfer and sharing application of data of medical records.Data of medical records are optimized,arranged and found faults for improving the correction of data.Conclusions The appearance of digitalized medical record storehouse is a substantive leap of management work of medical records,which embodies medical quality,medical records quality and clinic medical work effective combination.The procedures in setting up digitalized medical records storehouse are vital important.

关 键 词：病案 管理 数字化系统 流程 

分 类 号：R197.3[医药卫生—卫生事业管理]