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目的探索“数字化病案库”运行软件的设计重点,以帮助临床医务人员更好地提取和利用病案信息和数据。方法 (1)首先建立数字化病案库。(2)尽可能融合建院以来的所有病案及病案数据。(3)建立相应检索和统计病案信息窗口。直接采用“病案首页”项目作为统计、检索窗口。结果使“数字化病案库”成为即可以阅读病案原件内容,又可以提取病案信息和充分利用病案资源的综合软件。结论数字化病案库设计应该是:(1)符合临床医生使用病案的习惯。(2)操作简便。(3)数据准确、及时。(4)检索功能强大。(5)具有可避免医疗纠纷措施。(6)患者末次住院历次病案追踪等功能,与临床紧密结合,方便各类人员使用病案信息,让病案真正服务于临床一线。
Objective To explore the design priorities of the “Digital Medical Records” operating software to help clinicians better extract and utilize medical record information and data. Method (1) First, establish a digital medical record. (2) As far as possible, all the medical records and medical record data since the establishment of the hospital have been merged. (3) to establish the corresponding retrieval and statistical medical information window. Direct use of “medical records Home ” project as a statistical, search window. As a result, the “digital medical record database” becomes an integrated software that can read the original contents of the medical records, extract the medical records information and make full use of the medical records resources. Conclusion The design of digital medical records should be: (1) Accord with the habit of using medical records by clinicians. (2) easy to operate. (3) the data is accurate and timely. (4) powerful search. (5) Avoid medical disputes. (6) The last hospitalization of patients last case record tracking and other functions, and clinical close combination of various types of personnel to facilitate the use of medical record information, so that medical records really serve the clinical front line.