基于医院信息平台的手术麻醉流程改造探索

Exploration on the reconstruction of the surgical anesthesia process based on the hospital information platform

目的:为了规范手术麻醉流程,使手术麻醉信息在临床科室、手术室、麻醉科等医疗单元之间全面、准确地共享。方法:医院重新梳理了电子病历系统与手术麻醉系统的交互数据和流程,按照医院信息互联互通标准,基于医院信息平台,规范手术麻醉数据资源标准;涉及业务系统遵循医疗信息平台交互规范,采用SOAP 1.2通信协议和HL7 V3数据交换标准构建手术麻醉交互服务。结果:实现电子病历手术医嘱、手术申请、手术安排、麻醉记录、手术记录、病案首页手术信息填报等应用的互联互通。结论:此次信息系统改造,规范了手术麻醉流程,确保了手术麻醉信息的准确性,提高了手术麻醉的安全性和各医疗单元的协作效率。

Objective To standardize the surgical anesthesia process and comprehensively and accurately share the information of surgical anesthesia among clinical departments,operating room,anesthesiology department and other medical units.Methods The hospital reorganized the interactive data and process between the electronic medical record system and the surgical anesthesia system.The surgical anesthesia data resource standard is developed according to the hospital information interconnection standard based on the hospital information platform.The business system involved follows the interaction specification of the medical information platform.SOAP 1.2 communication protocol and HL7 V3 data exchange standard are used to construct the surgical anesthesia interaction service.Results The applications such as surgical advice of electronic medical records,surgical application,surgical arrangement,anesthesia records,surgical records,and surgical information filling in the first page of medical records are interconnected.Conclusion The transformation of the information system standardizes the surgical anesthesia process,ensures the accuracy of surgical anesthesia information,and improves the safety of surgical anesthesia and the cooperation efficiency of medical units.