病案信息索引电子化转换的实施

目的实现建院以来所有住院病人姓名索引卡片信息电子化,完善病案信息化管理。方法设计开发病历索引卡片信息补录模块,将旧病历姓名索引卡片信息通过＂补录模块＂录入系统,同时录入相应疾病的ICD-10编码。结果 ：补录了建院以来至医院运行HIS系统之前近30万人次的住院患者信息,并与医院运行的＂数字化病案＂系统成功集成。结论在满足历史住院信息查询需要的同时,提高了查询效率,并因疾病名称和编码的规范录入拓展了病案信息的科研应用价值。

The Implement of Electronic Transfer of Medical Records Information Index

Objectives to achieve electronic index cards information of all hospitalization patients since our hospital establishment and to perfect information management of medical records.Methods We design and develop additional recording module of medical records index cards inputting old index information through it with relevant ICD-10 coding.Results 300 thousand hospitalization patients’ information is additionally recorded from hospital establishment to before the running of HIS system,successfully integrating with the running system of digitalization medical records.Conclusions While satisfying the requirement of historical hospitalization information inquiry,it not only improves inquiry efficiency,but also expands the scientific research application value of medical records information by standard input of diseases name and coding.