电子病历评级实证材料管理系统建设实践

Construction Practice of the Management System of Empirical Materials for Grading Electronic Medical Records

目的根据国家卫健委提出的国家电子病历系统应用水平评级标准,研究为医院参加国家电子病历等级评审前的实证材料截图工作提供了信息化解决方案。方法搭建一套低代码平台,对基本的表单、功能进行创建维护,并为用户提供实现方式、截图、说明等录入功能。结果在平台中通过调用自定义外部链接的方式,将录入的条款内容、截图整合并导出标准的、符合实证材料格式规范的Word文档。结论摒弃了繁琐易错的手工整合操作,为待评级医院提供经验参考,赢得更多提升截图质量的时间,提高实证材料审核通过率。

Objective According to the standard of grading the application of the national electronic medical re-cord system proposed by the National Health Commission of the People's Republic of China,this study provides an information solution for the screenshot of empirical materials before hospitals participate in grading national elec-tronic medical records.Method A set of low-code platform was set up to create and maintain basic forms and functions,and provide users with input functions such as implementation methods,screenshots and descriptions.Result In the platform,the input terms and screenshots were integrated and exported into standard Word docu-ments that conformed to the format specifications of empirical materials by calling custom external links.Conclu-sion The cumbersome and error-prone manual integration operation is abandoned,which provides experience reference for hospitals to be graded,wins more time to improve the quality of screenshots,and improves the possi-bility of the approval of empirical materials.