门诊电子病历的应用

Application of Out-patient Electronic Medical Records

目的通过对门诊医生工作站系统的改造,实现要素提醒、强制完成、费用预警、处方量控制、电子化记录、病历本打印等智能化功能,解决传统门诊病历书写存在的问题,提高门诊病历规范化水平。方法通过信息化手段实现结构化病历电子书写。结果提高门诊病历书写质量,减少医疗纠纷,加大门诊就诊效率。结论利用信息化手段,提高门诊病历书写规范化水平。

Objective By reconstructing the system of out -patient doctors’workstation, a series of intelli-gent functions have been realized , such as factor reminder, compulsory completion, fee warning, prescription con-trol, electronic recording and medical record printing , which have solved problems existing in conventional out -patient medical records and thus improved the standardization of out -patient medical records.Methods Using in-formation -based strategy to realize structured electronic writing of medical records .Results Quality of out -pa-tient medical record writing has been improved and medical disputes have decreased , improving the efficiency of out-patient service.Conclusion Information -based strategy can improve out -patient medical record writing.