电子病历自动划价系统的设计与应用

Design and Implementation of the Automatically- Fee- Generating System in the Electronic Medical Records

目的拟在结构化电子病历撰写过程中增加自动划价功能,以规范门诊治疗收费。方法在结构化电子病历的基础上,将模板中"治疗处置节点"与医院信息系统中"收费项目"进行关联,医生在完成门诊病历书写的同时,自动生成治疗费用。在运行一段时间后,将实施前后的病人就诊时间、单病种病人就诊费用的波动情况进行对比。结果在不增加病人整体就诊时间的情况下通过门诊病历系统进行自动划价,单病种门诊治疗的收费更趋一致。结论电子病历系统治疗项目与收费项目的关联,有助于完善电子病历,规范门诊收费标准。

Objective To develop automatically - fee - generating function in outpatient electronic dental records to regulate the charge process. Method On the basis of the structured electronic medical records, ＂treatment disposal node＂ and ＂charge i- tems＂ were linked in the template to generate fee automatically. After operation for a period of time, the clinic time and the fluc- tuation of charges for two diseases were evaluated. Result With the automatically - fee - generating function, the charges for single disease were more consistently without increase in the overall clinic time. Conclusion With the association of treatment items and charging items, the content of electronic medical record can be improved and outpatient charging can be standardized.