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电子病历系统的研究与开发 总被引:56,自引:10,他引:56
目的研究与开发电子病历(CPR)系统,以实现病人信息的采集、加工、存储、传输和服务。方法通过建立结构化病历,开发文体编辑器,建立数据库安全性技术、在线帮助知识、实时监控技术、打印控制技术以及功能扩展技术来实现CPR系统。结果通过上述技术建立起来的CPR系统已在两所三级医院使用。实践证实,该系统运行良好、安全稳定、易维护、通用性好,提高了医疗质量和临床工作效率。结论①建立结构化病历是实现CPR的基础;②开发专用编辑器是实现CPR的关键;③拥有完备的数据库安全性技术是启动CPR的保障;④构建在线帮助“知识库”是辅助医生提高临床决策水平的有效途径;⑤CPR系统是提高病历质量的有效措施;⑥CPR是提高病历书写效率的有效方法。 相似文献
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我院实施电子病历的路径 总被引:1,自引:0,他引:1
黄俊星 《江苏卫生事业管理》2009,20(6):20-21
电子病历是医院信息系统的主要组成部分,结构化是电子病历的发展方向,信息集成是电子病历系统取代传统病历的核心要素,确保电子病历的安全性是实施电子病历的前提.实施电子病历可提高医院的工作质量、效率及病人满意度. 相似文献
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目的设计与开发神经内科急诊电子病历,以实现对神经内科急诊病人信息的采集、加工、存储和传输。方法以Oracle为后台数据库、Powerbuilder 6.5为前台开发工具,通过建立神经内科结构化病历,实现神经内科电子病历系统。结果该病历系统已在神经内科急诊使用,系统运行良好,达到了存储和传输病人信息、快速查询的目的。结论该系统能对医疗过程实施科学管理和智能化控制,有效提高临床医疗质量,提高医生书写病历的效率与质量,积累大量病历资料,方便临床、科研工作,为将来实现决策支持、规范和辅助治疗打下基础。 相似文献
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目的 开发新一代电子病历系统,实现临床医生结构化描述语言信息快速采集,方便临床信息集成与数据复用。方法 建立电子病历结构化描述语言模型,将临床规范化数据与描述性文本信息融为一体,实现重要医疗事件的表达和标识,达到临床信息的有效利用和医生快速数据录入。讨论 该模型实现了电子病历的模板表达和医生自由文本数据录入,通过自然语言实时处理技术,保障了电子病历的质量控制。结论 结构化描述语言电子病历模型允许医生自由文本数据录入,支持临床信息复用以及结构化数据处理,能实现临床数据快速采集,具有临床文档质量控制功能,是新一代电子病历发展的重要方向。 相似文献
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门诊电子病历的应用 总被引:1,自引:0,他引:1
易应萍 《中国医疗器械信息》2008,14(10):58-61
门诊电子病历是按病历书写规范设计,采用基于XML技术,结构化描述各类病历,实现病历内容的格式化和数据化,规范日常诊疗数据,实现完整、统一和标准的数据管理,并集成了数据、文本、图形、图片、影像等。同时由于其具有永久性、适时性、连续性,医生可随时调用病人的历史病历及检查结果,对病情的发展、观察、诊治都具有重要的意义。我院从2006年开始实行门诊电子病历,取得了较好的效果,有效地促进了病历质量的提高及保管,提高了门诊的诊疗水平。主要做法:以门诊电子病历为核心整合HIS、LIS、内窥镜等系统信息;以规范为准则设计门诊电子病历内容和格式;以制度为保障确保门诊电子病历系统的健康发展。主要体会:做好计算机基础培训作为项目实施的前题;做好应用培训作为项目实施的根本;做好病历模板作为项目实施的保障。 相似文献
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电子病历特征及其设计方法探讨 总被引:18,自引:3,他引:15
电子病历的界定可从两个方面考虑,一是其与HIS的关系;二是其主要特征。电子病历占据HIS逻辑结构层的主要部分,HIS是外壳,电子病历是内容。电子病历的主要特征是信息关联和数据的结构化存储及处理。电子病历取代纸病历须克服其先天不足:真伪性或称为可验证性、安全性、个人隐私权保护等。数字签名和信息隐藏技术是解决以上问题的较好办法。电子病历的功能和智能化水平取决于其关联设计的程度。 相似文献
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结构化电子病历的应用探讨 总被引:2,自引:1,他引:1
通过对比8000份纸质病历和结构化电子病历,从病案完成的速度和质量以及科研查询和质量等方面分析评价结构化电子病历的使用价值,讨论结构化电子病历的优势及实施过程中存在的问题。 相似文献
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A systematic review of computer-based patient record systems and quality of care: more randomized clinical trials or a broader approach? 总被引:2,自引:0,他引:2
Cyrille Delpierre Lise Cuzin Judith Fillaux Muriel Alvarez Patrice Massip Thierry Lang 《International journal for quality in health care》2004,16(5):407-416
PURPOSE: To analyse the impact of computer-based patient record systems (CBPRS) on medical practice, quality of care, and user and patient satisfaction. DATA SOURCES: Manual and electronic search of the Medline, Cochrane, and Embase databases. STUDY SELECTION: Selected articles were published from 2000 to March 2003. CBPRS was defined as computer software designed to be used by clinicians as a direct aid in clinical decision making. To be included, the systems should have recorded patient characteristics and offered online advice, or information or reminders specific to clinicians during the consultation. DATA EXTRACTION: Keywords used for the search were: electronic record, informatic record, electronic medical record, electronic patient record, patient order entry, computer-based patient system, clinical decision support systems, and evaluation. RESULTS: Twenty-six articles were selected. Use of a CBPRS was perceived favourably by physicians, with studies of satisfaction being mainly positive. A positive impact of CBPRS on preventive care was observed in all three studies where this criterion was examined. The 12 studies evaluating the impact on medical practice and guidelines compliance showed that positive experiences were as frequent as experiences showing no benefit. None of the six studies analysing the impact of CBPRS on patient outcomes reported any benefit. CONCLUSIONS: CBPRS increased user and patient satisfaction, which might lead to significant improvements in medical care practices. However, the studies on the impact of CBPRS on patient outcomes and quality of care were not conclusive. Alternative approaches considering social, cultural, and organizational factors may be needed to evaluate the usefulness of CBPRS. 相似文献
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Morgan JD 《Topics in health information management》1994,14(4):36-43
Public and patient access to medical records has been severely limited through policies limiting physical and timely access and intellectual understanding of content. New expectations of patient/public access and control have arisen accompanying the new paradigms of health care delivery and health information (computer-based patient records). Examples from these new paradigms are personalized and presented in information system contexts from bedside to community settings. Patient and family involvement in care delivery, education, assessment, and control of privacy are explored. A personalized confidentiality/security/privacy module of the computer-based patient record is suggested. 相似文献
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Picukaric JM 《Journal of AHIMA / American Health Information Management Association》1993,64(6):41-2, 44, 46-8
With the introduction of the computer-based patient record, the role of "medical record director" will be changed to that of "health information manager." This piece argues that health information managers, as a result of their education and experience, are the most qualified to serve as administrators of the data banks that the new technologies will require. 相似文献
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The need for accurate, timely, and complete clinical information has become critical as health care organizations compete on the basis of cost and quality. The automation of clinical documentation as part of the development of the computer-based patient record is a vital step in providing such information. As processes such as clinical documentation become automated, it is important that they are first redesigned both to maximize the capabilities of the new system and to increase their operational efficiencies. Riverside HealthCare in Kankakee, Illinois recognized this opportunity and successfully redesigned and automated its clinical documentation in 6 months. The article describes the necessary organizational commitment and project structure. Resource dedication, staff empowerment, physician involvement, and vendor partnership also are discussed. In addition, the documentation redesign, automation objectives, and lessons learned are reviewed. 相似文献
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The Providence experience provides a model which encompasses both preparation for a computer-based patient record and a physician-oriented approach to achieving quality documentation for the physician component of the patient record. The study comparing Providence to a similar medical center demonstrated the value of the new system in achieving quality patient records. Many hospitals in the Seattle area, including Overlake, now use this system or variations of it. 相似文献
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