以慢性肾病管理为主导的随访信息系统建立与应用

The Establishment and Application of the Follow-up Information System Led by the Management of Chronic Kidney Disease

目的:建立适合慢性肾病管理模式的信息系统,以提高随访工作质量和效率,同时为临床科研、教学提供有力依据。方法:根据慢性肾病管理中心运行模式,随访信息系统共设计15个功能模块:患者列表、基本信息、体格检查、实验室检查、辅助检查、用药情况、健康教育、营养宣教、预约提醒、评估表、住院病历查询、结案、数据统计、打印。结果:使用该系统后,CKD专职人员工作效率和质量显著提高:建立一份完整的患者档案及数据录入需时由45分钟缩短至25分钟;数据采集、录入错漏率由5.34‰下降至0.55‰;患者满意度由95.6%提高至98.9%。结论:该系统的建立,有利于对慢性肾病患者进行规范、有效管理;使患者健康教育工作更规范,方便,快捷,便于操作;以及对数据的高效管理。

Objective： To establish an information system which adapts to the chronic kidney disease management mode, so as to improve the quality and efficiency of follow-up work, and provide a strong basis for clinical research and teaching. Methods： According to the operation mode of the chronic kidney disease management center, the foUow-up information system includes 15 functional modules： patient list, basic information, physical examination, laboratory examination, auxiliary examination, medication, health education, nutrition education, appointment and reminder, assessment form, query of medical records, case closing, data statistics and printing. Results： After the system is used, the work efficiency and quality of full-time CKD personnel are significantly improved; the time required to establish a complete patient file and enter data reduces from 45 minutes to 25 minutes; the error rate of data collection and entry decreases from 5.34‰, to 0.55‰; and patient satisfaction increases from 95.6% to 98.9%. Conclusion： The establishment of this system is good for the standardized and effective management of patients with chronic kidney disease; the health education work of patients is more standardized, convenient, fast and convenient to operate; and data is effectively managed.