JCI理念导入下的门诊电子病历实践与思考

太和医院以JCI理念为指导优化以电子病历为核心的医院信息化建设,尤其是门诊电子病历系统的实施、管理及应用。笔者首先根据门诊电子病历信息的连续性、可及性和安全性,结合JCI评估标准,介绍门诊电子病历系统实施方案以及门诊服务制度。然后由系统上线的实践和经验,总结了门诊电子病历实际应用中的不足之处。阐述了持续改进门诊电子病历界面、内容和功能的对策,提出JCI理念导入下门诊电子病历需要进一步探索的问题。

Practice and Thinking of Outpatient Electronic Medical Record under the Introduction of JCI Concept

Taihe Hospital takes JCI concept as the guidance to optimize the construction of hospital informatization with electronic medical record as the core,especially the implementation,management and application of outpatient electronic medical record system.Based on the continuity,accessibility and security of outpatient electronic medical record information and JCI evaluation criteria,this paper first introduces the implementation scheme of outpatient electronic medical record system and outpatient service system.Then,based on the practice and experience of the system,the deficiencies in the practical application of electronic medical record in outpatient service are summarized.This paper also expounds the countermeasures to continuously improve the interface,content and function of outpatient electronic medical record,and puts forward the problems that need to be further explored under the introduction of JCI concept.