嵌入式结构化门诊电子病历在大型中医院的应用

Application of Embedded Structured Outpatient Medical Records in Large Traditional Chinese Medicine Hospital

目的通过对门诊医生工作平台的改造升级,实现病历内容结构化。方法建设以门诊电子病历为核心的门诊医生工作平台,结合大型中医院专科专病种类繁多的特色,分阶段推广、提升使用率、提高病历质量、优化流程。结果医疗服务能力显著增强,提升了患者的就医体验,极大提高了的医疗质量和效率。结论以信息化建设为抓手,促进智慧型中医院的升级,助力流程再造,提升了中医院精细化管理水平。

Objective Through the transformation and upgrading of the work platform for outpatient doctors, the contents of the medical records are structured. Methods To build an outpatient doctor work platform with outpatient electronic medical records as the core, combined with the features of a large variety of specialties of large Chinese medical hospitals, to promote and increase the use rate, improve the quality of medical records, and optimize the procedures in stages. Results The medical service capacity has been significantly enhanced, which has improved the patient＇s medical experience and greatly improved the quality and efficiency of medical care. Conclusion Taking information construction as the starting point, promoting the upgrading of smart Chinese hospitals and assisting in process reengineering has enhanced the fine management level of Chinese hospitals.