| 无锡市院前急救电子病历系统的开发设计与应用效果 |
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| 引用本文： | 张晓凡,王林,林长春,张振新,吴隽.无锡市院前急救电子病历系统的开发设计与应用效果[J].中国病案,2013,0(5):48-50. |
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| 作者姓名： | 张晓凡 王林 林长春 张振新 吴隽 |
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| 作者单位： | 张晓凡 (214023 无锡市 江苏省无锡市急救中心)； 王林 (214023 无锡市 江苏省无锡市急救中心)； 林长春 (214023 无锡市 江苏省无锡市急救中心)； 张振新 (214023 无锡市 江苏省无锡市急救中心)； 吴隽 (214023 无锡市 江苏省无锡市急救中心)； |
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| 摘 要： | 结合院前急救病历及其质控特性,设计院前急救电子病历系统。应用该系统3年,录入病历15万份,满足了急救管理和质量控制、科研数据储存、实时数据汇总等需求。电子病历的实施改变了院前管理松散的现况,增强了医疗质控力度,规范了院前医疗行为,提高了医疗质量,但在非文字与文字信息的整合、院前院内信息的共享、临床路径管理应用等方面还需进一步思考。
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| 关 键 词： | 院前急救 电子病历 质量管理 设计 应用 效果 |
Development Design and Application Effect of Pre-hospital Care Electronic Medical Record System in Wuxi City |
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| Zhang Xiaofan,Wang hn,Lin Changehun,Zhang Zhenxin,Wu Jun.Development Design and Application Effect of Pre-hospital Care Electronic Medical Record System in Wuxi City[J].Chinese Medical Record,2013,0(5):48-50. |
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| Authors: | Zhang Xiaofan Wang hn Lin Changehun Zhang Zhenxin Wu Jun |
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| Institution: | , Wuxi Pre-hosptial Care Center, Wuxi 214023, Jiangsu Province, China |
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| Abstract: | Combined with pre-hospital care medical record and its quality control characteristics, we designed and applied pre-hospital care electronic medical record system. This system had been applied for three years, entered 150000 medical records. It met the pre-hospital care management, quality control, research data storage, real time data eoUection etc. The implementation of the pre-hospital care electronic medical record system changed loose status of the pre-hospital management. It enhanced the medical quality control degree, standardized the pre-hospital care behavior, improved the pre-hospital care service quality, but there are still need further thinking and exploring in the words and text information integration, the information sharing between prehospital and in-hospital and clinical pathway management application. |
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| Keywords: | Pre-hospital care Electronic medical record Quality management Design Application Effect |
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