Ⅰ类切口手术抗菌药物检查中提高病案利用率的方法研究  

Methods Research on the Improvment of Medical Records Utilization in the Examination of Antimicrobials for Type Ⅰ Incision Operation

作　　者：张宏[1] 刘纳[1] 朱东喆[2] 朱光君[2] 

机构地区：[1]解放军第261医院,北京市100094 [2]北京军区总医院,北京市100700

出　　处：《中国病案》2013年第4期7-8,M0002,共3页Chinese Medical Record

摘　　要：为提高Ⅰ类切口手术使用抗菌药物的患者的病案调用效率,满足医疗质量控制需求。利用医院HIS系统病案数据库,使用SQL语句将Ⅰ类切口手术病例基本信息、诊断、手术、使用抗菌药物的品种、预防用药时机以及用药时间是否合理等相关联的信息调阅比对,有效查找出问题病例,并根据发现的问题进一步追踪研究。此方法充分利用电子病历信息,极大地减少了下架纸质病案的数量,改进了Ⅰ类切口手术使用抗菌药物检查方式,提高了供给病案信息的工作效率。In order to improve the access and utilization efficiency of the medical records with antimicrobials used for Type I op- eration incision, and satisfy the requirements of medical quality control. With the help of hospital medical record database in the HIS system, compare related information such as the basic information of type I incision operation, diagnosis, operation, what kind of an- tibiotics was used, prevention medication opportunity and reasonable medication time. Then find out medical records with problems effectively and conduct further track research according to the problems found out. This method makes full use of electronic medical records information and reduces the number of the off shelf paper medical records, and improves the inspection way of antimicrobials used in type I incision operation efficiently. Therefore, it improves the working efficiency of supplied medical records information.

关 键 词：抗菌药物 Ⅰ类手术切口 监控信息 

分 类 号：R619[医药卫生—外科学]