门(急)诊病案首页系统设计与思考

Design and Thinking of the Homepage System of Medical Records in Outpatient (Emergency) Department

结合门(急)诊工作特点和流程,搭建包括基本信息、就诊信息、诊疗信息、费用信息4个主要内容的门(急)诊病案首页系统框架,从患者信息维护、号源管理、门诊医生工作站、门诊电子病历等系统自动提取数据,实现了门(急)诊批量医疗数据的采集与汇总,为提升门(急)诊精细化管理能力、开展门(急)诊综合评价和探索门(急)诊医保支付改革等工作提供了参考。门(急)诊病案首页填报缺陷、门(急)诊数据上报及时性和准确性等问题是下一步改进重点。

Combined with the characteristics and process of Outpatient(Emergency)Department,a system framework for the homepage of medical records in Outpatient(Emergency)Department was established,which included four main contents:general information,medical information,diagnosis and treatment information,and cost information.An automated data collection system was also developed,which extracted data from patient information maintenance,number source management,outpatient doctor workstations,outpatient electronic medical records,and other systems,achieving the collection and summary of batch medical data for patients in Outpatient(Emergency)Department,which provided reference for improving the refined management ability of outpatient services,carrying out the comprehensive evaluation of Outptient(Emergency)Department and exploring the reform of medical inserance payment.The defects of filling in the homepage of medical records,the timeliness and accuracy of data reporting in Outpatient(Emergency)Department are the next improvement focus.