综合医院发热门诊信息化建设对传染病监测预警及登记报告的影响

Influence of the informatization construction of fever clinics in general hospital on the surveillance,early warning,and registration report of infectious diseases

目的完善发热门诊患者个人信息和诊疗信息,提高传染病监测和报告质量,缩短新发、突发传染病预警时间。方法2020年10月,在海南省人民医院信息系统(HIS)中构建一个新的信息采集模块,设计嵌入患者个人信息、诊疗信息等内容,包括患者症状体征、流行病学史、采样送检及治疗等选项,与医院信息系统存储的其他数据互联互通,建立较完备的数据库,自动提取数据生成电子病历及各项登记表和监测报表。结果完善患者个人信息,形成患者个人健康档案基线资料;自动生成门诊病历及各项登记表和监测报表,提高信息的准确性及实现无纸化办公;设定传染病报卡提醒,提高传染病报告及时率及降低漏报率;提高传染病监测质量,缩短新发、突发传染病预警时间。结论完善发热门诊信息化建设可以提升综合医院传染病登记报告质量和监测预警水平,为国家传染病防控大数据提供更准确的数据。

Objective To perfect the personal information,diagnosis and treatment information of fever outpatients,improve the quality of infectious diseases surveillance and registration report,and shorten the early warning time for new and emerging infectious diseases.Methods In October 2020,a new information collection module was constructed in the hospital information system(HIS)of Hainan General Hospital.The design embedded patient personal information,diagnosis and treatment information,including a series of options such as symptoms and signs,epidemiological history,sampling and examination,treatment.Then the information was interconnected with other data stored in the hospital information system to establish a relatively complete database,and automatically extract the data to generate electronic medical records,various registration forms and monitoring reports.Results This project had improved the patients’personal information,formed the baseline data of the patients’personal health files,realized automatic generation of outpatient medical records and various registration forms and monitoring reports,improved the accuracy of information,realized paperless of office,set up reminder for infectious disease report card,improved the timeliness rate of infectious diseases report and reduced the missing report rate,improved the quality of infectious diseases surveillance,and shortened the early warning time for new and emerging infectious diseases.Conclusion Informatization construction and improvement of fever clinics can improve the quality of infectious diseases registration reports and the level of surveillance and early warning in general hospitals,and provide more accurate data for the national infectious disease prevention and control Big Data.