基于病案科构架的随诊信息服务平台设计  

The Design of Follow-up Clinic Information Service Platform based on the Framework of Medical Records Department

作　　者：樊美娜[1] 王凯鹏[1] 

机构地区：[1]中国医学科学院肿瘤医院病案室,北京市100021

出　　处：《中国病案》2015年第5期29-32,共4页Chinese Medical Record

基　　金：中国癌症基金会北京希望马拉松专项基金赞助(LC2014L15)

摘　　要：对肿瘤患者进行院后定期的随诊随访,可以有效帮助患者康复,长期收集的数据也可以更好地帮助医生提高临床诊疗水平。某肿瘤专科医院利用日趋成熟的计算机技术、网络技术及数据库技术,通过3年的探索与实践,构建了以病案科随诊业务为中心的随诊信息化管理平台。平台使用标准统一的结构化接口工具,内嵌病案首页信息检索及随诊统计报表等功能,对接病案图像数字化扫描系统,借助移动通讯技术增加了短信、微信、APP等为辅助随诊手段。最终通过科室随诊业务流程再造,成功实现了病案随诊工作管理模式的转型,解决原有随访方式效率低、获取数据不完整、数据不准确、归集挖掘力度不够等难题。To conduct regular follow-up and treatment of tumor patients could help the rehabilitation of them effectively, and the long term of data collection could also help the doctors improve their clinical treatment level. With the application of daily maturing computer technology, network and database technology, the tumor hospital established a follow-up information management platform cored with follow-up service in medical records department after three years of investigation and practice. The platform adopted standard and unique structuring port instrument, embedded the functions included information searching of medical records home pages and follow-up statistical form, which could connect to the image digitization scan system of medical records and took short messages, Wechat, APP and so on as assisted follow-up methods with the help of mobile communication technology Therefore, we realized the transition of medical records follow-up work successfully through the process reengineering of follow-up service within departments, and solved the original problems such as low efficiency follow-up mode, incomplete or inaccurate data as well as insufficient collection and excavation.

关 键 词：病案科 随诊 信息平台 设计 

分 类 号：R197.3[医药卫生—卫生事业管理] TP311.13[医药卫生—公共卫生与预防医学]