电子健康档案研制及其在连续护理模式中的应用

The manufacture of Electronic Health Records and its application in continuous nursing model

目的:创建连续护理模式信息化平台,使临床及社区护士能够充分利用现代化工具及手段服务于慢性病患者的动态管理与随访分析。方法:建立慢性病患者健康档案数据库,利用PHP+APACHE+ACCESS研制"电子健康档案管理系统",从数据录入、数据管理、数据查询、数据传输及基本统计分析等方面进行了研究开发。结果:建立了与纸质调查表形式一致的可视界面进行数据录入,使医院—社区—患者3方面实现信息共享。结论:电子健康档案的建立使连续护理应用于慢性病患者动态管理及随访分析得以实现,为医院社区实现转诊提供信息保障,为医院、社区及患者提供检索的便利,为医疗卫生事业实现全面信息化奠定了基础。

Objective： Through creating information- based platform of continuous nursing, clinical and community nurses can take full advantage of modem tools and means in order to serve dynamic management and follow-up analysis for chronic diseases. Methods： With establishing health file database of chronic diseases, nurses could take use of PHP＋APACHE＋ACCESS to develop ＂Electronic Health Records Management System＂. There were beneficial research and development in data entry, data management, data inquiry, data transmission and basic statistical analysis. Results： The study established a visual interface which was consistent with paper-based questionnaire for data entry. So hospital - community - patients could share information together. Conclusion： Chronic diseases patients＇ dynamic management and follow-up analysis can come true through the establishment of Electronic Health Records. It also can provide information security of referral for hospital and community, promote searching convenience for three parts, and settle a foundation for comprehensive information modernization of medical health enterprise.