结构化电子病历在我院的应用

结构化电子病历（EMR）足目前国内医院正在普及的新工作项目,是数字化医院的必备条件。医院病案室是伤病员住院信息的收集、整理、存放、提供和服务利用的重要部门。本文阐述我院全面开展普及结构化EMR的前期与初期,病案管理人员要先学好、用好、宣传好。并从中找出存在的问题以及解决问题的办法,以保障新版EMR顺利跨越磨合期。     

实习医师病历书写的现状与措施

病历书写可拓宽实习医师的临床视野,培养临床思维能力,提高医疗综合素质。但随着公众法律及维权意识的增强、《医疗事故处理条例》的出台和医疗纠纷的日益增多,病历质量越来越重要,实习医师病历书写标准也越来越高。本文对当前实习医师书写病历存在的问题进行分析探讨,并提出应对措施。     

医院临床数据中心建设与应用

为解决医疗记录报告单的管理混乱问题,文章提出了医院临床数据中心体系架构,主要从系统整体架构、层次结构以及关键技术实现等方面进行了阐述,实现了基于Ensemble集成平台的医疗记录报告单数字化集中归档,生成PDF格式的报告单,为医护人员及病人提供各类应用服务。医生借助电子病历里调阅PDF格式的医疗记录报告单,解决了电子病历与各临床信息系统之间的信息集成,提高了医院的服务质量。     

A comparison of electronic records to paper records in mental health centers.

OBJECTIVE: Medication documentation is a critical aspect of quality patient care. The current study examined whether electronic medical records provide medication documentation that is more complete and faster to retrieve than traditional paper records. METHOD: This study involves a comparison of archived paper medical records to recent electronic medical records through chart review. A convenient sample of three large community mental health centers in Indiana was used. Medical charts for 180 patients with schizophrenia were rated on a checklist composed of 16 items that was adapted from a national project. Documentation that existed before implementation of the electronic medical record system was compared with that after implementation at each of the three centers. The main outcome measures were completeness and retrieval time of medication documentation. RESULTS: Electronic medical records provided medication documentation that was more complete and faster to retrieve than paper records across all centers and within each center. On average, electronic medical records were 40% more complete and 20% faster to retrieve. CONCLUSION: Electronic records have potential to improve medication management for patients in mental health centers over traditional records. However, medication documentation for patients diagnosed with schizophrenia was found to be deficient in many areas, regardless of documentation format.     

Attitudes of medical faculty physicians about taking occupational history

OBJECTIVES: To evaluate occupational history taking, as a detailed occupational history is the most effective means for proper diagnosis of occupational illness. METHODS: In order to determine the attitudes of 66 physicians working in Dokuz Eylül Medical Faculty Hospital about taking occupational history, 269 patient records were examined. RESULTS: It was detected that 43.9% of physicians took no occupational history from any of their patients. Occupational history was obtained from 81.8% of the patients in clinics where standard examination forms were in regular use. CONCLUSION: We found that physicians were not in the habit of taking occupational histories.     

Exclusive contracts between hospitals and physicians: the antitrust issues

Exclusive contracts between hospitals and physicians are common. In most instances they raise no anticompetitive concerns. However, especially in rural markets, exclusive contracts may be used to foreclose actual and potential competitors and thereby decrease competition. The courts should weigh the benefits and costs of exclusive contracts in these areas. © 1998 John Wiley & Sons, Ltd.     

Evaluation of a labeling system to indicate the presence of an advance directive in a hospital medical record.

OBJECTIVE: To investigate the accuracy of one hospital's system to indicate whether an advance directive exists within a patient's medical record. DESIGN: Medical record review while patients were hospitalized. SETTING: Internal medicine residency program within a tertiary care hospital. STUDY PARTICIPANTS: Patients admitted to four internal medicine services between 25 October 2000 and 6 December 2000. MAIN OUTCOME MEASURES: Presence of an advance directive and a label in medical records were recorded, along with patient demographics, and sensitivity, specificity, and accuracy were calculated. RESULTS: Four of 125 medical records (3%) contained advance directives. Sensitivity of a label for an advance directive was 25% [95% confidence interval (CI) 1-81%], specificity was 62% (95% CI 53-71%), and accuracy was 61% (95% CI 52-69%). CONCLUSIONS: Use of the hospital's labeling system to indicate the presence of advance directives was found to be highly inaccurate. Failure to correctly follow or understand the intended labeling procedure was the most likely source of error. Hospitals should include plans to check the accuracy of protocols when they are adopted to ensure that they are performing as intended.     

某三级甲等医院提高病历质量的做法

目的通过改变管理思路和模式,提高医院病历书写质量。方法分别安排返聘专家对重点终末病历和中高级职称医师对普通终末病历逐份进行检查,查找病历中的质量缺陷,对存在问题有针对性地加强培训,同时建立相应的奖惩机制。结果病历终末质量有了明显提高,合格率保持在98％以上,医疗纠纷大大减少。结论加大对病历终末质量的检查力度,杜绝书写者的侥幸心理,增强各级质控人员的质控意识,为职能部门管理和培训提供重要依据,此举是提高病历质量的一种有效方法。     

Teaching clinically experienced physicians communication skills. A review of evaluation studies

CONTEXT: Interest in the teaching of communication skills in medical schools has increased since the early seventies but, despite this growing interest, relatively limited curricular time is spent on the teaching of communication skills. The limited attention to the teaching of these skills applies even more to the physicians' clinical years, when attention becomes highly focused on biomedical and technical competence. Continuing training after medical school is necessary to refresh knowledge and skills, to prohibit decline of performance and to establish further improvements. OBJECTIVE: This review provides an overview of evaluation studies of communication skills training programmes for clinically experienced physicians who have finished their undergraduate medical education. The review focuses on the training objectives, the applied educational methods, the evaluation methodology and instruments, and training results. METHODS: CD-ROM searches were performed on MedLine and Psychlit, with a focus on effect-studies dating from 1985. RESULTS: Fifteen papers on 14 evaluation studies were located. There appears to be some consistency in the aims and methods of the training programmes. Course effect measurements include physician self-ratings, independent behavioural observations and patient outcomes. Most of the studies used inadequate research designs. Overall, positive training effects on the physicians' communication behaviour are found on half or less of the observed behaviours. Studies with the most adequate designs report the fewest positive training effects. CONCLUSION: Several reasons are discussed to explain the limited findings. Future research may benefit from research methods which focus on factors that inhibit and facilitate the physicians' implementation of skills into actual behaviours in daily practice.     

日本数字化医院的现状及发展趋势

本文就日本数字化医疗发展的基本特点-由科室数字化到全院数字化的实施策略以及区域医疗、家庭医疗的解决实施作一介绍.在日本,数字化医院的实现是通过检查结果数据库和多种支持的应答交流工具链接了的诊疗支援系统来完成的,除了在日常的诊疗中应用以外、还应用于地区医疗和预防医疗等场所.     

我国电子病历研究进展

电子病历已经上升到个人终生健康记录的层次,它的实现依赖于整个医疗过程的信息化.我国的电子病历研究与应用在临床信息系统、病历编辑、床旁移动应用、知识库应用以及电子病历的集成等基本问题方面取得了不同程度的进展.而对电子病历的认识不到位、缺乏电子病历共享项目的示范、缺乏配套的医疗制度法规等因素影响电子病历的发展.     

医院无线临床信息系统架构及实现

无线临床信息系统是目前医院信息化建设的一个热点领域。医院的HIS、LIS、PACS等信息还散落在各个不同的系统中,临床对于以病人为中心,统一病人相关临床数据的要求日益迫切。无线临床信息系统是医院电子病历发展应用的必然阶段,它能极大程度的解决医护信息共享问题,使临床医护人员更贴近病患,能及时在床边处理医嘱。本文将以本院建设的成功案例为蓝本,着重介绍医院各个信息系统与电子病历集成的无线临床信息系统的架构。     

构建智能型数字化医院

总结了我国医院数字化建设10多年的经验,从建设理念、基本特征、实现目标和应包括的内容等4个方面对数字化医院进行全面论述,指出数字化医院应坚持以人为本和以患者为中心,必须具备全方位、全过程、可管理、智能化、无纸化、标准化、高效率、高安全等8个条件,目的是实现临床业务智能化、患者服务智能化、资产管理智能化、医院物流智能化、管理决策智能化和楼宇建筑智能化,基本内容是7大系统、5大主索引和4大中心。     

大型医院电子病历信息系统的设计及实现

从理念框架．系统框架,数据集成,权限与安全控制、身份索引及临床路径构成等方面,介绍了以电子病历为核心的三甲医院信息平台设计的基本理念与流程,从质量控制、信息共享等方面阐述了电子病历系统设计流程与功能。结合某三甲医院信息平台中电子病历信息系统实际案例,介绍了结构化电子病历系统的设计构成、使用优势及其效果,以及存在不足之处。     

黑龙江省综合医院病案室人员现状分析与研究

通过对黑龙江省6个市36家综合医院病案室人员现状调查,了解、明确病案室人员现状及存在的问题,提出相应的改进策略,为病案室人员结构的合理发展提供参考。     

Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents

Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is essential to assuring accurate and reliable medical records. Yet, prior literature reveals surgery residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because the evaluation of and reimbursement for healthcare service delivery relies on the physician's ability to produce appropriate medical records, which then get translated into billable codes. This pilot study suggests hospitals may incur significant financial loss in revenue due to inaccurate clinical documentation by residents. Thus, educational training for medical residents in the area of clinical documentation and hospital-specific coding practices may prove financially advantageous.     

医院信息系统整体柔性分析

医院信息系统是一项复杂的系统工程,要求在多变的环境下,与时俱进,作出改变。针对盲目强调柔性而可能导致的非柔性,提出医院信息系统需要适度柔性,以达到真正柔性的目的 ,并通过研究医院信息系统各分系统的运行关系并结合当前政策环境,确立电子病历系统以及医保系统应当具备相对高的柔性。     

The approaches to learning of specialist physicians

Recent studies have provided information about the approaches to studying and learning used by medical students. However, no published work is available on the approaches of practising doctors. The Adelaide Diagnostic Learning Inventory for Medical Students (ADLIMS) was modified and administered to a random sample of 308 physicians (internists). Generally speaking, physicians seem to have lower scores on surface approach and higher scores on deep approach than students. Level of clinical experience did not appear to influence this finding. However, marked differences were apparent between the approaches adopted by physicians with additional postgraduate academic training and those without. The former had a much stronger tendency to use the more desirable deep approach. The latter seemed to rely more on the less desirable surface approach. Further longitudinal studies will be required to determine whether this difference is attributable to self-selection of those who have already developed a deep approach or is causally related to a training in research. Although these findings must be interpreted with caution, some implications are clear. Physicians should become more aware of the way they learn and about the way they teach. Inappropriate patterns of learning may be entrenched during the undergraduate and immediate postgraduate years. If validated, these findings may provide support for the inclusion of research projects in medical school and during specialist training.