基于环节控制模式规范记录口腔局部麻醉方案  

Recording oral local anesthesia scheme based on the procedure control mode

作　　者：王春燕[1] 徐刚[2] 孙辉[2] 李旭奎[1] 

机构地区：[1]西安交通大学口腔医院口腔颌面外科,西安710004 [2]西安交通大学口腔医院信息统计中心,西安710004

出　　处：《中国医学教育技术》2013年第5期573-576,共4页China Medical Education Technology

基　　金：2012年西安交通大学口腔医院新技术项目"基于网络化的口腔门诊电子病历建设及数据挖掘初探"

摘　　要：目的探讨规范记录口腔局部麻醉方案的环节控制模式。方法基于结构化门诊电子病历系统,以控制口腔局部麻醉方案的记录范式、内容片断模板和医师书写病历三个环节建立环节控制模式。结果基于病历记录环节控制模式,西安交通大学口腔医院相关门诊临床科室已经实现了规范记录口腔局部麻醉方案的目标。结论病历记录环节控制模式,不仅可以规范记录口腔局部麻醉方案、控制病历质量和服务于教学科研,而且具备应用通用性属性。Objective To explore the procedure control mode （ PCM ） for recording oral local anesthesia scheme .Methods Based on the structured outpatient electronic medical records system , PCM was established by controlling the recording paradigm of oral local anesthesia scheme , content fragments template and doctor＇s medical record writing .Results The goal of establishing recording oral local anesthesia scheme via PCM has been achieved in the related outpatient clinical departments of Stomatology Hospital of Xi＇an Jiaotong University .Conclusion PCM can be applied not only in standardizing recording oral local anesthesia scheme but also in controlling medical records quality and serving teaching and research .In addition, PCM has the property of universal application .

关 键 词：环节控制模式 内容片断模板 规范 局部麻醉方案 记录范式 

分 类 号：R-058[医药卫生] G434[文化科学—教育学]