可移动病历系统在帕金森病中的应用及培训作用

Application of Mobile Medical Records System in Parkinson's Diseases

已有的电子病历系统多安装于非移动台式个人计算机上,体量大、不能移动,因此不能满足查房等需要病史在病房中跟随医师移动的实际工作需求,即存在医师办公室到患者床旁的"10米断层"。特别是帕金森病患者的诊治过程中有大量的量表评估需求,需要记录医师与患者的实时互动。为克服上述缺点,满足帕金森病的特殊诊治需求,目前研发一种基于iOS系统的可移动帕金森病电子病历系统。该系统装载于iPad mini中,由基本信息、知情同意、必填病历、选填病历四大部分组成,具有灵敏便携的特点,极大地提高了查房效率、增加了医师对帕金森病患者病情把握的准确性、同时为进修医师和研究生的培训提供了良好手段。

Nowadays, the electronic medical record existing are usually installed in immovable personal computers, thus cannot easily assist medical routines such as ward rounds because of its immobility, which means the existing of ＂10 meters of Fault＂, especially in the treatment process of Parkinson＇s disease, we need to recordsthe interaction between the doctors and patients timely because of the requirements of large scale of assessment tables. To overcome this flaw and satisfy the special needs in the diagnostic and treatment process of Parkinson＇s disease, we invented an ios-based portable electronic medical record system for Parkinson＇s disease. The system is loaded in i Pad mini and consists by general information, informed consent, mandatory record and optional record. The system has elevated the efficiency of ward rounds, increased the accuracy of disease evaluation and acted as useful tool in the education of visiting physicians and postgraduate students.