前列腺癌门诊科研病历系统构建  

Construction of Medical Record System for Scientific Research of Prostate Cancer Patients in Outpatient Department

作　　者：施挺[1] 高旭[1] 王海峰[1] 王燕[1] 许传亮[1] 孙颖浩[1] SHI Ting GAO Xu WANG Haifeng WANG Yan XU Chuanliang SUN Yinghao(Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai 20043)

机构地区：[1]第二军医大学附属长海医院泌尿外科,上海200433

出　　处：《解放军医院管理杂志》2017年第9期826-828,共3页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：目的回顾总结前列腺癌门诊科研病历系统的构建过程及实际临床应用的体会。方法为了解决门诊就诊的前列腺癌患者病历资料不全导致无法进行科研统计分析的困扰,医院泌尿外科与信息科合作,于2016年1月开始开发可与医院门急诊医生工作站对接的前列腺癌门诊科研病历系统。首先将所有可能于门诊就诊的前列腺癌患者分成不同类别,然后根据各类型患者的特点分别设计病历模块,最后在临床试用过程中不断进行缺陷修复和质量优化。结果根据前列腺癌患者的不同特点,将前列腺癌门诊科研病历系统细分为确诊后治疗前模块、根治术后模块、初始内分泌治疗模块及初始放疗模块,在每个模块中设置一定数量的关键信息以供填写,并提供可选病史以满足扩展性需求。在临床试用过程中,针对部分患者就诊时病历资料不全导致无法完整录入所有信息的情况,将各模块中需要填写的关键内容分为必填项和选填项,并加入时间限制,在保证信息完整的基础上对实际临床操作提供便利。此外,加入下拉框及可选框来简化输入过程,以提高临床操作效率。最后,实现系统的数据质控和导出功能,可以根据需要随时查看门诊医师填写病历的数量和质量,也可以批量导出数据以供临床研究使用。结论前列腺癌科研病历系统的构建不但很大程度上增加前列腺癌患者信息的获取,也为科研与临床工作的结合统一提供一个范例。Objective To review and summarize the construction process of the medical record system for scientific research of prostate cancer patients in outpatient department and the experiences of the clinical application. Methods In order to solve the problem that the medical information of prostate cancer patients in outpatient department was often lacking and unable to be used in statistical analysis,we cooperated with the hospital information department to construct the scientific medical record system which can be connected with the hospital doctor workstation since January 2016. First of all,we divided patients with prostate cancer into different categories. Then we design case modules according to the characteristics of each category. Finally,we made defect repair and quality optimization in the clinical trial process. Results According to the different characteristics of the patients with prostate cancer,our prostate cancer record system was subdivided into 4 modules,such as module suit for the time between diagnosis and treatment,module suit for the time after operation,module suit for the time after endocrine treatment and module suit for the time after radiotherapy. We set a certain number of key information for filling,and provide the optional part to meet expanding demand in each module. In the process of clinical trial,we separate the key information in each module into mandatory information and optional information,and we also add a time limit in order to ensure the integrity for records and the convenience for using. In addition,we also add the drop-down box and the optional box to simplify the input process for improving the efficiency of the clinical application. Finally,we achieve the quality control and export function,so that we can check the number and quality of medical records at any time or export data for clinical research. Conclusion The construction of the medical record system for prostate cancer not only greatly increases the available information of patients with prostate cancer,but also pro

关 键 词：前列腺癌 病历 门诊 数据库 

分 类 号：R197.32[医药卫生—卫生事业管理]