临床输血电子病历及首页管理模式的建立  

The establishment of electronic blood transfusion records and a novel home pages management model

作　　者：王雷萍 戴芳[2] 胡锋兰[3] 邓超干[4] 张印则 孟庆宝 WANG Leiping;DAI Fang;HU Fenglan;DENG Chaogan;ZHANG Yinze;MENG Qinbao(ShenZhen People＇s Hospital, Shenzhen 518020, China;Peking University Shenzhen Hospital;Shenzhen Nanshan People＇s Hospital;Shenzhen Luohu People＇s Hospital;Shenzhen University General Hospital)

机构地区：[1]深圳市人民医院,广东深圳518020 [2]北京大学深圳医院 [3]深圳市南山区人民医院 [4]深圳市罗湖区人民医院 [5]深圳大学总医院

出　　处：《中国输血杂志》2018年第5期451-454,共4页Chinese Journal of Blood Transfusion

基　　金：中国医学科学院医学与健康科技创新工程(2016-12M-3-024)

摘　　要：在临床输血路径引导下的输血闭环式管理中,将输血前评估、输血过程管理、输血后效果评价、输血不良反应处理等相关记录自动生成可编辑的输血病历电子文档,汇总成临床输血病历。借鉴病历首页的管理模式设计输血病历首页,通过输血病历首页监控输血病历书写的及时性和病历的完整性,通过输血病历的上传和汇总分析获得区域性临床输血大数据。这种新的管理模式不仅可使输血病历更趋规范化、减少项目遗漏和书写不及时现象,还可避免医务人员重复记录的问题。Blood transfusion records, like pre-evaluations, blood infusion process, post-evaluations, adverse events, and any related records, could be summarized automatically and converted into editable electronic clinical documents, which can be achieved during the closed-loop management of clinical blood transfusion. The management model was designed sharing the key properties of the Home Page Medical Record model, which monitors the instantaneity and integrality of clinical records and collects regional clinical status to generate blood transfusion big data. This new management model brings several advantages ： The standardization of clinical blood transfusion, the reduction of omitted or late records, and the decrease of repetitive paper work for medical professionals. It also provides a strategy for the collation of regional statistics to generate clinical blood transfusion big data.

关 键 词：输血病历 输血病历首页 输血大数据 

分 类 号：R457.1[医药卫生—治疗学] R197.323.2[医药卫生—临床医学]