基于XML的结构化电子病历系统的实施及问题探讨

The Implementation Based on Structural Electronic Medical Record System and Problems Discussion

目的探讨结构化电子病历系统在医院的实施情况。方法针对结构化电子病历系统特点,提出合理的实施计划及流程。对主任医师、主治医师、经治医师进行分级培训和实践操作,而经治医师是培训的主体。继之正式启用该系统,并对病历书写进行实时监控。结果根据计划流程安排,顺利实施该系统,达到了预期目的。结论保证系统顺利实施,医院管理者下定决心必须启用是关键;各职能部门及临床科室的协调配合是成功实施的前提;完好的培训是实施的基础。

Objective To discuss the implementation situation of structural electronic medical record.Methods Aiming at the characteristic of structural electronic medical record system,this paper puts forward reasonable implementation plan and process.Having training for different levels of doctors and practice operation,while physician-in-charge are the focus of the training.Have real-time monitor of medical record writing by using this system.Results It achieves expectation goal through using the system according to process arrangement.Conclusion The determination of using this system is the key to make sure its smooth implement.The premise of it is coordination between functional department and clinical department.The basis of implement is perfect training.