基于临床路径的半结构化电子病历建设研究  

Construction Study on Semi-structured Electronic Medical Record System on Account of Clinical Pathway

作　　者：钟文明[1] 刘叶珍[1] 吴智娟[1] 刘晓峰[1] 卢光进[1] 

机构地区：[1]深圳市宝安区妇幼保健院,深圳市518133

出　　处：《中国病案》2013年第8期50-52,共3页Chinese Medical Record

基　　金：深圳市科技局课题(编号:201103054)

摘　　要：探讨基于临床路径的半结构化电子病历建设的基本理念、流程、功能模块等,并评价其实施效果及存在问题。采用半结构化的电子病历有利于促进临床路径管理,提高医疗质量,规范医疗行为及降低医疗成本。建设基于临床路径的半结构化电子病历系统具有重大而深远的意义,应加大实施临床路径的病种覆盖力度,同时大力发展以患者为中心的新型半结构化电子病历。To explore basic idea, flow-sheet and functional modules of construction of semi - structured electronic medical record （EMR） system on account of clinical pathway, and e,~aluate its implementation effect and existing problems. Adopting semi-struc- tured EMR was in favor of clinical pathway management, raised medical quality, standarded medical behavior and cut down medical cost. There was great and far- reaching significance to construct semi- EMR system on account of clinical pathway. We should in- crease the implementation of entity covering of clinical pathway, and rapidly develop neotype semi - EMR system taking patients as the center.

关 键 词：临床路径 半结构化 电子病历 医疗质量 

分 类 号：R197.3[医药卫生—卫生事业管理]