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目的:建立适合肝病专科门诊需求的电子病历系统。方法:首先进行系统的需求分析和结构设计,再进行系统软件设计,最后录入病历档案检验系统功能。结果:肝病专科电子病案系统软件实现了包括录入、储存、查询、检索、输出和统计的基本功能,并且已录入既往积累的4000余份患者个人病历档案,提高了病历录入效率,实现了患者资料的实时更新,通过数据库基本统计功能获得了既往积累门诊个人病历档案的整体信息,为临床与科研的开展提供了基础。结论:成功建立适合肝病专科病人随访与管理的电子病案系统,获得开发和使用数据库的初步经验,有利于临床诊疗与科研。
OBJECTIVE: To establish an electronic medical record system suitable for the needs of specialized outpatient liver disease. Methods: First, the system needs analysis and structural design, and then the system software design, and finally record the medical records file inspection system functions. Results: The electronic specialty medical record system of liver disease realizes the basic functions of inputting, storing, querying, retrieving, outputting and counting. It has also recorded over 4,000 personal medical record files accumulated in the past, improved the efficiency of patient record entry, Real-time updates, through the basic statistical functions of the database was accumulated in the past accumulated personal medical records of the overall file information for clinical and scientific research to provide the foundation. Conclusion: The successful establishment of an electronic medical record system for follow-up and management of liver disease specialist patients and the initial experience of developing and using databases are beneficial to clinical diagnosis and treatment.