整形外科电子病历医学摄影管理模式的探讨  

Discussion on Medical Photography Management Mode of Electronic Medical Records for Plastic Surgery Patients

作　　者：郑金龙 栾杰 Zheng Jinlong;Luan Jie(Plastic Surgery Hospital of Chinese Academy of Medical Sciences,Beijing 100144,China;不详)

机构地区：[1]中国医学科学院整形外科医院,北京市100144

出　　处：《中国病案》2020年第3期7-9,36,共4页Chinese Medical Record

摘　　要：为客观、真实、形象地反映手术治疗效果,提高医疗、教学、研究水平,对整形外科患者电子病历医学摄影管理模式进行研究,依据某院各类整形外科诊断及手术医学摄影要求,参照美国整形外科教育基金会临床摄影委员会制定的整形外科的摄影规范,制定某院整形外科患者医学摄影拍摄标准,并将标准通过信息技术嵌入电子病历,建立医学摄影上传平台及质控平台,质控结果实时通过电子病历反馈至临床科室。通过电子病历医学摄影管理,记录每位患者进行整形外科手术、操作的电子病历中都具有一套完整、规范的医学摄影,它既能作为整形外科手术治疗效果的重要评价依据,又高度可信地反映客观存在。电子病历医学摄影管理是规范医学摄影工作的可行方案。In order to reflect the effect of surgical treatment objectively,truthfully and vividly,and improve the level of medical treatment,teaching,and research,this article studies the medical photography management model of electronic medical records for orthopedic patients.According to the requirements of various plastic surgery diagnosis and surgical medical photography in a hospital,with reference to the Plastic Surgery Photography Standards formulated by the clinical photography committee of the American plastic surgery education foundation,the Medical Photography Standards for Plastic Surgery Patients of a Hospital was formulated,and the standards were embedded into electronic medical records through information technology to establish a medical photography upload platform and quality control platform.The quality control results were fed back to the clinical department in real time through the electronic medical record.Through the medical photography management of electronic medical records,each patient who performs plastic surgery and operates the electronic medical records of the patient had a complete and standardized set of medical photography,which could be used as an important basis for evaluating the effect of plastic surgery,and highly reliable reflection of objective existence.Electronic medical records medical photography management was a feasible solution to standardize medical photography work.

关 键 词：整形外科 电子病历 医学摄影 质控管理 

分 类 号：R197.3[医药卫生—卫生事业管理]