一种牙髓病尖周病电子病历的设计和实现

目的:创建一种指引和辅助牙髓病尖周病临床诊疗行为、系统化记录诊疗数据的电子病历模型。方法:依照牙髓病尖周病较权威的诊治规范和步骤,归纳总结出一套符合临床诊疗规程的医学逻辑,设计出计算机实现算法和流程、用MSSQLServer7. 0数据库保存电子病历的诊疗逻辑及数据,采用Delphi程序设计完成电子病历的操作界面、医学逻辑及相关辅助功能。结果:系统由挂号开始,初复诊分离,历经全身性病史、主诉与现病史、临床检查、X线影像分析、临床诊断、制定治疗计划等步骤,详实、系统、规范地记录患者的牙髓病尖周病资料,诊治过程清晰明了,操作快捷方便。系统已经在口腔诊所稳定运行了3年,病案逾千例。结论:本系统有效地规范了医生对牙髓病尖周病的诊治行为,对治疗及愈后情况可以实施全程追踪观察,对研究疾病的发生、发展和转归,探索新的治疗方案都起到了重要作用。

Design and implementation of an electronic patient record system of endodontics

AIM:To develope an electronic patient record model system for guiding the endodontical diagnosis and treatment,and for storage of complete endodontic data.METHODS:Based on authoritative textbooks and research papers,a set of endodontic diagnostic rules and treament procedures were analyzed,arranged and built firstly.Secondly a corresponding computer algorithm and workflow is designed.Then MS SQL Server 7.0 database is used to store data.Finally a Delphi program is developed to implement the operative interface and medical logic.RESULTS:This system is built on a workflow started from enquiring dental history and followed by observation,testings,X-ray examination,diagnosis and treatment plans.Endodontic data are collected step by step.The program is clear.The system has been used for 3 years in our clinics and more than 1000 cases were managed.CONCLUSION:This system has greatly enhanced the quality of endodontic diagnosis and treament,improved the observation of illness evolvement,facilitated the judgement of treatment effect,and boosted the research for more effective treament skills.This endodontics EPR system has been proved to be benefit to patients,dentists,researchers and clinic managers.