摘要
目的研究与开发电子病历(CPR)系统,以实现病人信息的采集、加工、存储、传输和服务。方法通过建立结构化病历,开发文体编辑器,建立数据库安全性技术、在线帮助知识、实时监控技术、打印控制技术以及功能扩展技术来实现CPR系统。结果通过上述技术建立起来的CPR系统已在两所三级医院使用。实践证实,该系统运行良好、安全稳定、易维护、通用性好,提高了医疗质量和临床工作效率。结论①建立结构化病历是实现CPR的基础;②开发专用编辑器是实现CPR的关键;③拥有完备的数据库安全性技术是启动CPR的保障;④构建在线帮助“知识库”是辅助医生提高临床决策水平的有效途径;⑤CPR系统是提高病历质量的有效措施;⑥CPR是提高病历书写效率的有效方法。
Objective To research and develop a computer-based patient record (CPR) system so as to realize the collection, processing, storage, transmission and application of patient information. Methods A CPR system was accomplished through developing a structural patient record, a text editor, techniques of database security, a knowledge base of on-line help, real-time monitoring, print control and function expansion. Results The CPR system, established with the above techniques, was put into use in two third-tier hospitals. It was proved via practice that the system, sound in operation, safe and stable, easy to maintain, and compatible, enhanced medical quality and clinical efficiency. Conclusion ①Creating a structural patient record is the basis of realizing CPR. ②Developing a specialized editor is the key to bringing about CPR. ③Possessing perfect database security techniques is the guarantee for starting CPR. ④Constructing a knowledge base of on-line help is an effective way to help doctors raise the level of their clinical decisions. ⑤The CPR system is an effective means of improving the quality of patient records.⑥The CPR system is also an effective means of improving the efficiency of patient record writing.
出处
《中华医院管理杂志》
2004年第4期204-206,共3页
Chinese Journal of Hospital Administration
基金
广东省科技计划基金(2002B30608)
