急诊信息系统建设实践

The Practice and Experience of Emergency Information System Construction

目的:为提升急诊患者安全,给急诊患者管理提供更加明确详细的数据,结合急诊业务需求,设计并建设具有急诊特色的急诊信息系统。方法:以医院信息平台、无线网和物联网为依托,建设能够满足急诊科室闭环管理、整合临床决策支持的急诊系统。结果:预检系统能够自动帮助护士对患者危重程度进行评级,并将预检结果与医生共享;急诊患者流向的细分记录能够清晰地展示患者在院内进行医疗行为的轨迹,方便医生护士对患者进行追踪管理;交接班功能充分考虑急诊医生与门诊工作模式的区别,确保患者跨越多天的一次诊疗记录能够贯穿始终;急诊电子病历能够整合患者在门诊、住院的各类检查检验和病历记录,为医生提供诊断所需的各种必要信息。结论:在医院通过应用急诊信息系统,能够为医生的诊疗工作和护士的患者管理工作提供决策支持和帮助。

Objective： To improve patient security, provide more clearly detailed data for emergency patient management, combining with the requirement of emergency business, we designed and builded emergency information system which had emergency characteristics. Methods： We builded emergency system which could meet closed-loop management and integrated clinical decision support based on hospital information platforms, wireless networks and Internet of Things. Result： The preview system could help nurses evaluated the severity of patients and shared the result with the doctors. The record of emergency patients flow could show the trace of patient, then doctors and nurses could trace patients conveniently. To ensure the continuity of the records that through some days, when we designed shift function, we fully considered the difference between emergency operation mode and outpatient operation mode. Emergency EMR integrated inspection and examination results in outpatient and inpatient, providing necessary information for doctors. Conclusion： The emergency information system provided decision support and help for the treatment of doctor and the patient management of nurse.