基于JCI评审标准的门诊电子病历应用

The Application of Electronic Medical Records in Outpatients Department Based on JCI Review Standards

对门诊电子病案信息的连续性、可及性和安全性进行研究。通过对JCI评审标准的理解以及在JCI认证准备过程中的实践和体会,找出门诊电子病案实际应用中的不足。阐述以第五版JCI标准为指导对门诊电子病案界面、内容及功能等方面持续改进的对策,通过门诊患者预检筛查确定初始评估项目,另设门诊病案小结及门诊病案概述,划分医务人员对门诊病案系统查阅和操作权限,论述整改后门诊病案系统的优势,并提出后JCI时代门诊电子病案需要进一步探讨的问题。

To conduct an analysis on the continuity, accessibility, and security of the information of electronic medical records. Through the practice and experience in the preparation process of JCI certification and the understanding of JCI review standards, to find out the defects existing in the practical application process of electronic medical records in outpatients department. To elaborate the aspects such as interface, content and function of the electronic medical records in outpatients department standardized by the fifth version of JCI standard.To ensure the primary assessment items by the preview screening of the patients in outpatient department, design the summary of outpatient medical records, divide the reading and operating rights of the medical staff to the outpatient medical records system, elaborate the advantages of the system after the reform, and put forward the problems of outpatient medical records that needed further investigation in the latter JCI era.