城市社区卫生服务中心电子病历系统优化服务环境探讨  

Optimization of services at urban community health centers esing the electronic medical record system

作　　者：武桂英[1] 赵新平[1] 李哲 田国栋 沈伟珍 彭德荣 

机构地区：[1]复旦大学公共卫生学院,上海200032 [2]上海市闸北区卫生局 [3]上海市闸北区卫生科技与信息中心 [4]上海市闸北区彭浦街道新村社区卫生服务中心

出　　处：《中华医院管理杂志》2012年第5期338-341,共4页Chinese Journal of Hospital Administration

基　　金：国家科技部“十一五”支撑项目（2008BA152B06）

摘　　要：构建了城市社区卫生服务中心基于优化服务环境的电子病历系统，并依托医生工作站，实现门诊医疗服务信息一体化。此系统在5个方面优化了门诊医疗服务环境：①各项医疗服务流程实现电子化操作，提高了工作效率和服务质量；②电子病历模板的使用减少了医生书写病史的时间，提高了问诊和检查时间；③通过LIS、PACS及心电系统等，可以查阅病人检验结果和影像诊断资料，掌握病人健康状况；④通过诊疗记录子系统，可以调阅病人既往病史的电子记录，了解疾病控制情况；⑤通过医联共享子系统，可以获得病人在“上海医联”机构就诊的病历记录，了解病人的疾病程度，以便制定治疗方案。电子病历系统的开发与应用，既提高了全科医生的诊疗水平，又为病人提供了良好的医疗服务环境。An electronic medical record（EMR）system is built at urban community health centers to optimize services, achieving information integration of outpatient medical services based on the doctors＇ workstation. This system has optimized service at the outpatient clinics in the following： 1. Digitizing service processes for higher efficiency and service quality; 2. Using EMR templates to save doctors~ time in writing medical records for more of their time in patient inquiries and checks; 3. Using LIS,PACs and ECG/EKC systems to check lab results and imaging diagnostics of patients; 4. Using the diagnostic and therapy record sub-system to check electronic records of the patients for consulting their health history; 5. Using the Shanghai Medical Alliance ~ s （SMA） shared sub-system to acquire patients ~ medical records at SMA medical institutions, learning their conditions for their therapies. EMR, when it is built and put into use, can help improve GP＇s diagnostics and therapeutics, and provide better care to the outpatients as well.

关 键 词：社区卫生服务中心 电子病历 服务环境 优化 

分 类 号：R197.324[医药卫生—卫生事业管理]