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目的探索如何在诊疗信息化医疗机构中推动严重临床异常病例/事件监测工作。方法试点期间,通过临床医生主动报告结合医院/疾控中心传染病管理人员主动搜索的联合报告方式,实施严重临床异常病例/事件监测工作。结果上海市长宁区监测点采用半结构式HIS系统,通过联合报告方式,正式运行7个月内,共上报49例监测病例,其中临床医生主动报告4例,管理人员主动搜索报告45例,症候群包括38例重症肺炎监测病例,10例发热伴皮疹监测病例,1例脑炎监测病例。所有病例最终均未被判定为严重临床异常病例/事件。结论严重临床异常病例/事件监测系统是现有监测体系的有益补充,但在采用半结构式HIS系统的医疗机构中的应用仍需改进。
Objective To explore how to promote the monitoring of serious clinical abnormal cases / events in medical information and medical institutions. Methods During the pilot period, clinical cases of serious abnormalities / events were monitored by clinicians taking the initiative to report combined reports of active searches by infectious disease managers in hospitals / CDCs. Results The monitoring site of Changning District in Shanghai used semi-structural HIS system. Through the joint reporting mode, 49 monitoring cases were officially reported within 7 months. Among them, 4 were reported voluntarily by clinicians and 45 were actively searched by management staff. The syndromes included 38 cases of severe pneumonia monitoring cases, 10 cases of fever with rash monitoring cases, 1 case of encephalitis monitoring. None of the cases were ultimately classified as serious clinical abnormalities / events. Conclusion Serious clinical abnormal case / event monitoring system is a useful supplement to the existing monitoring system, but the application in semi-structural HIS system in medical institutions still needs improvement.