麻醉信息管理系统的设计与临床实践

Development and clinical evaluation of an anesthesia information management system

目的 探讨数字化手术室建设中麻醉信息管理系统的设计、实现和临床实践.方法 利用信息集成技术系统全面接入各类床旁监测设备,自动地记录、处理、储存围术期患者信息 利用数据挖掘技术系统对采集的大量患者信息进行统计分析,并通过计算机辅助患者评分体系和临床决策支持系统,自动对患者进行评估分析,指导麻醉医生进行合理安全的医疗行为 系统同时将医疗行为记录数字化,自动生成标准化表格,减少手工劳动量,规范优化工作流程.结果 建立了完整的麻醉信息管理系统,采集、存储、分析、归档各种医疗设备中患者信息,生成各类麻醉文书.临床决策支持系统辅助麻醉医生做出合理的医疗行为.结论 麻醉信息管理系统的使用,对于提高麻醉质量、降低医患风险、辅助医疗举证有十分重要的意义.

Objective To study the design, implementation and clinical evaluation of an anesthesia information management system. Methods To record, process and store peri-operative patient data automatically, all kinds of bedside monitoring equipments are connected into the system based on information integrating technology after a statistical analysis of those patient data by data mining technology, patient status can be evaluated automatically based on risk prediction standard and decision support system, and then anesthetist could perform reasonable and safe clinical processes with clinical processes electronically recorded, standard record tables could be generated, and clinical workflow is optimized, as well. Results With the system, kinds of patient data could be collected, stored, analyzed and archived,kinds of anesthesia documents could be generated, and patient status could be evaluated to support clinic decision. Conclusion The anesthesia information management system is useful for improving anesthesia quality, decreasing risk of patient and clinician, and aiding to provid clinical proof.