门诊电子病历的应用  

Application of Out-patient Electronic Medical Records

作　　者：陈杰[1] 吴乐乐[1] 魏民[1] 高白[1] 戴晶晶[1] 项耀钧[2] CHEN Jie WU Le - le WEI Min GAO Bai DAI Jing - jing XlANG Yao - jun(Information Department,Changhai Hospital, Second Military Medical University, Shanghai 200433 Hospital Office, Changhai Hospital, Second Military Medical University, Shanghai 200433)

机构地区：[1]第二军医大学长海医院信息科,上海200433 [2]第二军医大学长海医院院办,上海200433

出　　处：《解放军医院管理杂志》2016年第10期932-933,共2页Hospital Administration Journal of Chinese People's Liberation Army

基　　金：数字化医疗关键技术集成与应用示范(2012AA02A612);提高"未来医院"应对第三方支付风险的信息化手段的研究(CH201511);住院医师规范化培训考核系统研究(20124401)

摘　　要：目的通过对门诊医生工作站系统的改造,实现要素提醒、强制完成、费用预警、处方量控制、电子化记录、病历本打印等智能化功能,解决传统门诊病历书写存在的问题,提高门诊病历规范化水平。方法通过信息化手段实现结构化病历电子书写。结果提高门诊病历书写质量,减少医疗纠纷,加大门诊就诊效率。结论利用信息化手段,提高门诊病历书写规范化水平。Objective By reconstructing the system of out -patient doctors’workstation, a series of intelli-gent functions have been realized , such as factor reminder, compulsory completion, fee warning, prescription con-trol, electronic recording and medical record printing , which have solved problems existing in conventional out -patient medical records and thus improved the standardization of out -patient medical records.Methods Using in-formation -based strategy to realize structured electronic writing of medical records .Results Quality of out -pa-tient medical record writing has been improved and medical disputes have decreased , improving the efficiency of out-patient service.Conclusion Information -based strategy can improve out -patient medical record writing.

关 键 词：门诊病历 门诊医生站 

分 类 号：R197.32[医药卫生—卫生事业管理]