专科电子病历及其集成方式探讨

Discussion about Specialized Electronic Medical Record and Integration Mode

目的:通过对专科电子病历及其集成方式优缺点分析,探索专科电子病历建设模式.方法:对首都医科大学附属北京友谊医院在用产科、眼科、口腔专科电子病历及集成方式进行归纳总结.结果:专科电子病历易于数据和应用同步集成,有效提高专科病历应用的契合度,对科室内不同病种具有通用性和扩展性.结论:基于电子病历系统标准化、集成化、智能化的要求,高度集成的专科电子病历在医疗效率、质量环节管控、数据完整性等方面功能更优.

Objective:To explore the construction mode of electronic medical record in specialty by analyzing the advantages and disadvantages of electronic medical record and its integration mode.Methods:The electronic medical records of obstetrics,ophthalmology and stomatology in Beijing Friendship Hospital Affiliated to Capital Medical University were summarized.Results:The electronic medical record of the specialized department is easy to integrate data and application simultaneously,effectively improve the fit of the application of the medical record of the specialized department,and has universality and expansibility for different diseases in the department.Conclusion:Based on the requirements of standardization,integration and intelligence of electronic medical record system,highly integrated specialized electronic medical record has better function in medical efficiency,quality control,data integrity and other aspects.