NICU病房早产儿日常病程记录结构化专科模板的建立  

Practice of Construction of Structured Template for Routine Course Record of Disease of Premature Infants in NICU Ward

作　　者：朱东喆[1] 胡晓明[1] 李莉[1] 崔英 Zhu Dongzhe;Hu Xiaoming;Li Li;Cui Ying(The Children’s Hospital Affiliated to The Capital Institute of Pediatrics,Beijing 100020,China;不详)

机构地区：[1]首都儿科研究所附属儿童医院,北京市100020

出　　处：《中国病案》2022年第2期30-32,共3页Chinese Medical Record

摘　　要：目的 分析NICU病房早产儿日常病程记录特点,探索构建结构化专科模板的方法。方法 采用帕累托排图法对某院NICU病房2018年1月1日-2019年12月31日出院的早产儿33份日常病程记录标准化后分类分析,建立结构化病历模版。结果 标准化项目归类为52项。主次分析累计百分比在≤80%的A类因素29项,占总比率的79.52%;80%-90%的6项,占总比率的9.90%;≥90%的17项,占总比率的10.58%。确定日常病程记录标准化项目36个,归为病情、治疗、呼吸支持、辅助检查4个大类,定义数据单位、数量规格和选项的标准化字典库,建立标准化模板。结论 由专科医师参与开发,以传统病历信息分析为基础构建早产儿专业特色结构化日常病程记录有助于提高病历结构化与临床实际的契合。Objective To analyze the characteristics of the routine course records of premature infants in the NICU ward and explore the method of building structured template.Methods To standardize the recording items of 33 routine course records of diseases from 2018 to 2019 in NICU ward.Then,according to the theories and methods such as Vilfredo Pareto Principle,we designed a structured medical record template by main items.Results The standardization items were classified as 52 categories.29 categories were A factors with the cumulative percentage of primary and secondary analysis ≤80%,accounting for 79.52% of the total ratio;6 items of 80% ~ 90%,accounting for 9.90% of the total ratio;17 categories≥90%,accounting for 10.58% of the total ratio.After the integration of basic items and specialized items,a new routine course record of disease from 4 dimensions(illness,treatment,respiratory support and examination) was constructed,36 standardized items were determined.Standardized dictionary database of data units,quantity specifications and options was also defined,and standardized template was established.Conclusion The special structured routine course record of disease of premature infants,which is developed with the participation of neonatalspecialists,is a beneficial attempt to the structuration of medical records.

关 键 词：电子病历 结构化病历 病案管理 早产儿 模版 

分 类 号：R722.6[医药卫生—儿科]