电子病历系统的设计与实现

Design and Implementation of Computer-based Patient Record System

针对目前电子病历中WORD作为病人医疗信息数字化处理器存在的问题,本文以科学规范、安全可靠、强化质控、提高效率、结构化存储、辅助决策、有机集成、扩展性好八项原则为设计思想,主要采用了八项技术方法实现电子病历系统:①建立电子病历的基本数据结构;②建立半结构化病历生成技术;③建立独特的病人信息采集编辑技术;④建立实时动态质量控制方法;⑤建立系统安全技术;⑥建立在线辅助知识库;⑦建立特殊打印技术;⑧建立系统维护技术。

In accordance with problems in WORD as processor in electric case history, the author based on the design thinking of eight principle such as standardizing data structure, ensuring security, reinforcing quality control, improving the efficiency, depositing structured file, making assistant decision, collecting information, extending function, the computer-based patient record system is implemented with eight techniques: Firstly, creating basic data structure of computer-based patient record; Secondly, producing technique of semi-structured patient record; Thirdly, achieving unique collecting and editing technique of patient information; Fourthly, establishing real time developmental quality control method; Fifthly, setting up system safety technique; Sixthly, constructing on line assistant knowledge base; Seventhly, developing special printing technique; Eighthly, performing system maintenance technique.