基于数据库技术的电子病案医疗文档的建立和管理

Establishment and management on electronic medical documents based on database technology.

目的:通过对比两种建立医疗文档的方法:模板文档和专用程序,阐明利用数据库技术建立医疗文档在电子病案系统中的重要性;方法:利用数据库技术,采用格式定义语言,编写专用程序来建立医疗文档;结果:建立的250张电子病案文档,近2年实践中,满足系统全数据库保存的要求,并能从格式,专业需要,使用方便,选择自由度,发展需要,安全等方面满足病案的要求,同时使这些文档的管理更具合理性和科学性;结论:数据库技术是建立电子病案医疗文档最佳方法,为病人信息在医院信息系统(HIS)的信息共享提供技术基础,满足远程医疗的技术需要。同时,其管理方法立足院情,并满足了医院发展的需要。

Objective By comparing the two ways of setting up medical documents: the template document and professional procedure, the paper shows the importance of setting up medical documents with the database technology in the electronic medical record system. Methods: We used Database technology to compile the professional procedure for the medical documents, with the format definition language. Results: In this way, we set up 250 electronic medical records within the recent 2 years, which can certify the systematical all-database preserve, and ensure the format, professional needs, convenience, selection, development, fit the needs of the medical documents. At the same time, the management to these documents became more reasonable and scientific. Conclusion: Database technology is the best way to set up the electronic medical record, and provides the technological base for the information sharing of the patients records in the HIS. And it's also useful to the telemedicine developments. The management, based on the circumstance of the hospital, brings more space for the development of the hospital.