门诊电子病历的实施与改进

Discussion on the Implementation and Improvement of the Clinic Electronic Medical Record

对门诊电子病历实施中存在问题和不足进行了调研,同时分析了门诊电子病历的数据共享、便捷化与智能化、查询分析等功能要求,以保障门诊电子病历顺利实施和高效应用。某院门诊电子病历实施初期存在漏填关键信息、诊疗信息录入速度慢,信息无法实时保存、死机、患者诊疗信息共享不畅和患者个人信息泄露等问题。某院通过加强计算机应用培训,电子病历模板中设置关联项和必填项、建立专业知识库和个性化病历模版、增设数据缓存,设置查阅权限和身份识别系统等措施解决系列问题。门诊电子病历实施中存在的问题既有普遍性又有个性,及时解决门诊电子病历实施中存在的问题是保障其顺利推广应用的前提和基础。实践证明,其整改措施具有很强的针对性和适用性,效果显著,值得借鉴和参考。

In order to ensure the smooth and efficient operation of the Clinic Electronic Medical Record in a hospital,investigated some problems using of its.The functional characteristics of the Clinic Electronic Medical Record are analyzed as data sharing,convenience and intelligence,query and analysis.The many problems are discovered by the survey in early implementation of electronic medical record in a hospital in Nanchang,such as missing items,diagnosis and treatment information entered slowly,unable to save in time,even system crashed,poor sharing and leakage of patients'diagnosis and treatment information.The many improving approaches are proposed such as enhancing education,setting associated items and required items,and establishing professional knowledge base and medical record template,increasing data cache,setting information viewing permission and identification system,and have achieved remarkable results in a hospital in Nanchang.It is thus clear that the problems in the implementation of the Clinic Electronic Medical Record solved in time is the premise and foundation to ensure its smooth implementation,the problems in the implementation of the Clinic Electronic Medical Record in a hospital in Nanchang are universal and individuality,the practice has proved that the specific measures proposed has strong pertinence and applicability,and the effect is remarkable,which is worth learning with reference.