嵌入式临床路径管理软件功能标准研究

目的：确定嵌入式临床路径电子化系统功能标准,满足临床电子病历系统应用的相关要求。方法：对病区医生进行访谈,从纸张临床路径应用中得到电子化临床路径的基本功能,从临床路径电子化软件切换应用中得到其附加功能,比较相关软件得到适合大型医院使用的能嵌入电子病历系统的临床路径软件的功能标准。结果：嵌入式临床路径的功能标准,其重要功能是患者临床处置列表、变异管理、评估与统计分析。结论：该研究对嵌入电子病历系统的临床路径电子化开发具有帮助作用。

Function Standard of Embedded Clinical Pathway Management Software

Objective To determine the function standard for the electronic system of the embedded clinical pathway and fulfill the demands of clinical electronic medical records system.Methods The functions of eCP were determined based on the interviews with the hospital staff and the implementation of paper-based clinical pathways,and additional functions generated by the shift from paper-based system to an electronic system.Moreover,the proposed standard functions embedded in electronic medical records for large hospital were compared by interviews with some vendors.Results eCP included displaying,recording,ordering,editing,variance,and statistics.Conclusion Standard functions required for eCP embedded in electronic medical records are proposed,and the functions for editing patient checklists,checking the occurrence of variance,and statistics are especially important.