建立受控医嘱术语实现医嘱执行全程管理  

Establishment of the Controlled & Terminologized Physician Order for Its Whole-Process Management

作　　者：林雪金 郭志旭[1] 陈大鹏[1] 陈金雄[1] 

机构地区：[1]南京军区福州总医院计算机应用与管理科,福建福州350025

出　　处：《中国医疗设备》2014年第2期93-95,共3页China Medical Devices

摘　　要：电子病历是数字化医院的核心,而医嘱录入系统是电子病历系统的主要内容,医嘱术语与医嘱结构不规范严重制约着数字化医院的建设与发展。本文首先指出了医嘱的重要性及其作用,分析了电子医嘱存在概念、术语、子项、对照、结构和录入不清晰和不规范问题,对医嘱规范化提出了术语要完整、结构要标准、录入要规范、对照要准确、职责要清晰、软件要完善等解决办法,最后阐述了医嘱规范化带来的主要效益。The electronic medical record is the core of digital hospitals, and the physician order entry system is the main content of the electronic medical record system. Unstandardized medical terminologies and physician order structures have greatly restricted the construction and development of the digital hospital. This paper first pointed out the importance and effects of the physician order, analyzed its unclear and unstandardized problems in the aspects of concepts, terms, subitems, contrasts, structures as well as input. Then, corresponding solutions to the problem were put forward including complete terminologies, standardized structures, well-defined input, accurate contrasts, clear responsibilities and perfect software. Finally, the paper expounded the main benefits of standardized physician orders.

关 键 词：数字化医院 电子病历 CPOE医嘱 医嘱术语 数据字典 

分 类 号：R197.32[医药卫生—卫生事业管理] R197.324[医药卫生—公共卫生与预防医学]