在数字字化病案中条码纸的妙用.docVIP

在数字化病案中条码纸的妙用 赖伏虎 王浩 陈连璞 罗霭华 罗洁樱 李苏建 （深圳市第八人民医院信息科 518101） 深圳市宝安区科技局科研立项（2002134） 【摘要】 目的 本项目力求突破条形码技术在病案借阅流通中传统应用的范畴，探索在医院数字化病案中条形码的新型应用。 方法 优化病案管理工作流程，在病案数字化扫描环节中，采用插入条码纸或定制带条码的病案表格等方法，发挥条形码快速识别、自动分类、准确排序的功能特性。 结果 整本病案在条码纸的分类标识下，由原先以流水号命名的扫描文档，自动归类成病案首页、出院记录、住院志、病程及其它记录、医嘱和医嘱单、护理文书、其它各种证明七大部分，自动排序产生有对应页码的病案目录，并自动标记主观病历和客观病历。 结论 在已有数字化病案管理系统的基础上，利用条码纸的分类识别，使得病案“扫描文档格式”排列有序，归类合理，有利于精确检索和快捷打印，从而实现更大的信息效益。 【关键词】 条形码 数字化 病案 Title the new application of bar-code in hospital medical record digitization. Written by Lai Fuhu, Wang Hao, Chen Lianpu. Shezhen 8th hospital, China, 518101 【Abstract】 Objective The project makes effort to break through the traditional application of bar-code technology in medical record circulation, to probe in the new application of the bar-code in hospital medical record digitization. Methods Optimizing the workflow of the medical record management, through inserting bar-code classification paper or printing the medical record form of bar-code in the medical record digital scanning section. Results With the support of bar-code technology, the whole medical record could automatically be classified from the scanning document into seven major sections. These sections are as follows: medical record home page, hospital discharge record, hospitalization record, course of disease and other taken notes, doctors order sheets, nursing instruments, and other medical certificates. A medical record content with corresponding page number is simultaneously automatically made. Automatically mark subjectivity medical record and objective medical record. Conclusion Base on the existing digital medical record management system, developing the new application of bar-code, can make medical record scans the document form arranged orderly, classified reasonably. It also do good to index and print, can improve the medical record management efficiency. Key words：Bar-code Digitization Medical record 目前病案信息化建设已是大势所趋，成为各家医院和卫生主管部门的共识。笔者做过一次普查