北京市麻醉科电子病历信息化及药品管理智能化系统建设现状分析  

Analysis of the current status of informatization of electronic medical records and intelligent drug management systems in anesthesia department in Beijing

作　　者：王丽薇[1] 杜海明 韩永正[1] 周阳[1] 李正迁[1] 曾鸿[1] 王军[1] 郭向阳[1] WANG Liwei;DU Haiming;HAN Yongzheng;ZHOU Yang;LI Zhengqian;ZENG Hong;WANG Jun;GUO Xiangyang(Department of Anesthesiology,Peking University Third Hospital,Beijing Clinical Anesthesia Quality Control and Improvement Center,Beijing 100191,China)

机构地区：[1]北京大学第三医院麻醉科北京市临床麻醉质量控制和改进中心,北京100191

出　　处：《麻醉安全与质控》2024年第4期196-200,共5页Perioperative Safety and Quality Assurance

基　　金：北京大学第三医院临床重点项目(BYSYZHKC2022103)。

摘　　要：目的探究北京市麻醉科电子病历信息化及药品管理智能化系统的建设现状。方法选取2021年1~12月北京市辖区内109家二级及以上医院上报的质控数据进行分析,对麻醉科电子病历信息化及药品管理智能化系统相关的质控指标实行动态管理,探讨其在临床麻醉及质控管理中的应用现状。结果截至2021年12月,64家医院(58.7%)启用麻醉科电子记录系统,63家(57.8%)医院启用电子化麻醉记录单,45家(41.3%)医院启用电子化术前访视记录单,49家(45.0%)医院启用电子化术后随访记录单,32家(29.4%)医院启用电子化麻醉恢复室记录单,23家(21.1%)医院配备智能药柜,68家(62.4%)医院配备彩色药品标签。朝阳区、海淀区、东城区、西城区麻醉科电子病历信息化医院数量较多,顺义区、门头沟区、通州区、平谷区上报的医院中只有1~2家医院启用麻醉信息管理系统,麻醉科电子病历信息化程度较低,怀柔区、密云区上报的医院中尚未启用麻醉信息管理系统。结论北京市部分区域麻醉电子病历信息化及药品管理智能化仍偏低、麻醉信息化建设滞后,需进一步加强麻醉质控管理标准化和医疗服务同质化建设。Objective To explore the current status of informatization of electronic medical records and intelligent drug management system in the department of anesthesiology at hospitals of secondary and higher level in Beijing.Methods The quality control data reported by 109 secondary and above hospitals in Beijing were selected and analyzed from January to December 2021.The quality control indexes related to the informatization of electronic medical records and drug management intelligent system in the department of anesthesiology were dynamically managed,and its application status in clinical anesthesia and quality control management was discussed.Results By December 2021,64 hospitals(58.7%)had enabled the electronic recording system of anesthesia department,63 hospitals(57.8%)had enabled the electronic anesthesia record sheet,45 hospitals(41.3%)had enabled the electronic preoperative visit record sheet,49 hospitals(45.0%)had enabled the electronic post-operative follow-up record sheet,32 hospitals(29.4%)had enabled the electronic post-anesthesia recovery room record sheet,and 23 hospitals(21.1%)were equipped with intelligent medicine cabinets,68 hospitals(62.4%)were equipped with color drug labels.Chaoyang District,Haidian District,Dongcheng District and Xicheng District have a large number of hospitals enabling electronic medical record informatization in the Department of anesthesiology.Among the hospitals reported in Shunyi District,Mentougou District,Tongzhou District and Pinggu District,only 1 or 2 hospitals have enabled the anesthesia information management system,the degree of electronic medical record informatization in the Department of anesthesiology is low,and the anesthesia information management system has not been enabled in the hospitals reported in Huairou District and Miyun District.Conclusion The level of the informatization of anesthesia electronic medical records and intelligent drug management in some districts of Beijing are still low,and the construction of anesthesia informatization is lagging b

关 键 词：电子病历 麻醉信息管理系统 药品管理 智能药柜 麻醉质控 

分 类 号：R95[医药卫生—药学]