基于电子病历系统的临床疾病诊断的应用效果评价  

Evaluation of Application Effect of Clinical Disease Diagnosis System Based on Electronic Medical Records

作　　者：高健[1] 杜静[2] 

机构地区：[1]南京医科大学附属淮安第一人民医院,江苏省淮安市黄河西路1号223300 [2]南京医科大学附属淮安第一人民医院统计室,江苏省淮安市黄河西路1号223300

出　　处：《中国数字医学》2017年第11期111-112,115,共3页China Digital Medicine

基　　金：国家档案局科技立项项目(编号:2015-R-34)~~

摘　　要：目的:评价电子病历系统应用于临床疾病诊断的效果。方法:采用统计学方法对实施临床疾病诊断字典库前后的疾病编码正确率和临床医师满意度进行分析。结果:采用临床疾病诊断字典库后诊断编码的正确率由实施前的56%提高至87%,临床医师的满意度由43.75%提高至80%,均明显有所提高(P<0.05)。结论:电子病历疾病模块的应用不仅保持了电子病历的规范,而且最大程度地体现了临床诊断的灵活性,为未来医院信息化的发展提供了更多的思路及参考依据。Objective： To evaluate the electronic medical record system used in clinical diagnosis of diseases. Methods： Using statistical methods to analyze the implementation of clinical diagnosis and disease dictionary encoding accuracy and clinicians＇ satisfaction. Results： The diagnostic accuracy rate of diagnosis of clinical disease after encoding dictionary from before the implementation of the 56% to 87%, the clinician＇s satisfaction degree increased from 43.75% to 80%, were significantly increased （P〈0.05）. Conclusion： The application of electronic medical record module can not only maintain the electronic medical record standard, and the maximum extent reflect the clinical diagnosis of the flexibility to provide more ideas and reference for the future development of hospital information system.

关 键 词：电子病历 疾病诊断 评价 

分 类 号：R319[医药卫生—基础医学] TP391[自动化与计算机技术—计算机应用技术]