摘要
目的:设计区域电子病案管理系统,实现病案的电子化管理。方法:该系统采用文件生成层、应用支撑层、管理平台层和应用服务层4层架构。通过调用OFD版式转化、电子签名认证、时间戳等病历归档服务,生成电子病案文件,在院内电子病案系统归档,再上传至区域电子病案管理系统。同时,搭建智能化质控规则引擎,对上传的电子病案文件进行全方位质量把控与评审。结果:8家试点单位实现常态化的电子病案文件生成和上传,目前已对接44316份电子病案文件。应用该系统可实现对病案的100%质控,并将评判结果呈现出来。结论:区域电子病案管理系统为病案的电子化、区域化管理提供了整体思路、技术规范和实施路径,有利于提高病案的管理水平和利用率。
Objective To design a regional management system to realize electronic medical record management in the hospital.Methods The system adopted a four-layer architecture involving in document generation layer,application support layer,management platform layer and application service layer.By calling OFD format conversion,electronic signature authentication,time stamp and other medical record filing services,the system generated electronic medical records,filed them in the hospital electronic medical record system,and then uploaded them to the regional electronic medical record management system.An intelligent quality control rule engine was built to control and evaluate the quality of the uploaded electronic medical records.Results Eight trial units realized normalized generation and uploading of electronic medical records,and 44316 electronic records were involved in.The application of the system allowed for complete quality control of the medical records and the presentation of the results of the evaluation.Conclusion The system developed provides overall thinking,technical standards and implementation pathway for the electronization and regional management of medical records,and also enhances the management and utilization of medical records.
作者
苏逸飞
鲍瀛
陈平
殷伟东
刘晓娇
SU Yi-fei;BAO Ying;CHEN Ping;YIN Wei-dong;LIU Xiao-jiao(Nanjing Health Information Center,Nanjing 210003,China;Nanjing Drum Tower Hospital,Nanjing 210008,China)
出处
《医疗卫生装备》
CAS
2020年第7期22-25,81,共5页
Chinese Medical Equipment Journal
基金
江苏省社会发展重大科技示范项目(BE2018607)。
关键词
OFD版式
电子病案
病案管理
区域化管理
电子签名
OFD format
electronic medical record
medical record management
regional management
electronic signature
