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结合院前急救病历及其质控特性,设计院前急救电子病历系统。应用该系统3年,录入病历15万份,满足了急救管理和质量控制、科研数据储存、实时数据汇总等需求。电子病历的实施改变了院前管理松散的现况,增强了医疗质控力度,规范了院前医疗行为,提高了医疗质量,但在非文字与文字信息的整合、院前院内信息的共享、临床路径管理应用等方面还需进一步思考。
Combined with pre-hospital emergency medical records and quality control features, the hospital designed the first-aid electronic medical record system. Application of the system for 3 years, record 150,000 medical records, to meet the emergency management and quality control, scientific research data storage, real-time data collection and other needs. The implementation of electronic medical records has changed the status quo of loose pre-hospital management, strengthened the quality control of medical services, standardized the pre-hospital medical behaviors and improved the quality of medical treatment. However, the integration of non-written and written information, Clinical path management applications need further thinking.