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原有的病案管理是建立在纸质病案的管理模式上,费时费力,而且无法实现病案质量的有效监控及病案数据的充分利用。而在已有电子病案系统的基础上如何实现病案数据的存储、审核查询、统计、分析及等共享功能,是开发病案管理系统最主要的问题。开发病案管理系统就要实现:以现有电子病案系统框架、存储结构,完成包括病案首页管理;病案的浏览;病案的追踪;病案质量控制和病人随诊管理的功能。经过一段时间的实际应用,系统紧密贴合医院针对病案管理的工作流程,满足了病案、临床、科研及管理部门的基本需求,并且已经取得了显著的效果。
The original medical record management was based on the management mode of paper medical records, which was time-consuming and laborious, and failed to achieve effective monitoring of case quality and full use of medical record data. How to realize the storage, review and query, statistics, analysis, and other sharing functions of medical record data on the basis of existing electronic medical record systems is the most important issue in the development of medical record management systems. The development of a medical record management system will require the realization of: the existing electronic medical record system framework and storage structure, including the management of the medical record home page; the browsing of medical records; the tracking of medical records; the quality control of patient records and the function of patient follow-up management. After a period of practical application, the system closely fits the hospital’s workflow for the management of medical records, satisfies the basic needs of the medical record, clinical, scientific research and management departments, and has achieved remarkable results.