武汉市某三甲医院肝病专科电子病历系统的初步建立.pdfVIP

第 25 卷第4 期 Vo 1.25 No.4 医学与社会 2012 年4 月 Medicine and Society Apr. 2012 • 29 • 武汉市某兰甲医院肝病专科电子病历系统的初步建立 方清1.2 郝友华1 李磊1 张振华1 王俊忠I 马德强 l 陈明发1 康健I 杨东亮 l 1 华中科技大学同济医学院附属同济医院临床免疫研究室，武汉，430030; 三峡大学第一临床医学院 宜昌市中心人民医院感染科，宜昌，443000 摘要 目的:建立适合肝病专科门诊需求的电子病历系统。方法:首先进行系统的需求分析和结构设计，再进行系统软 件设计，最后录入病历档案检验系统功能。结果:肝病专科电子病案系统软件实现了包括录入、储存、查询、检索、输出和统 计的基本功能，并且已录入既往积累的 4000 余份患者个人病历档案，提高了病历录入效率，实现了患者资料的实时更新，通 过数据库基本统计功能获得了既往积累门诊个人病历档案的整体信息，为临床与科研的开展提供了基础。结论:成功建立 适合肝病专科病人随访与管理的电子病案系统，获得开发和使用数据库的初步经验，有利于临床诊疗与科研。 关键词 电子病历系统;系统设计:肝病 中图分类号 RI97.323.1 文献标识码 A DO I.1O.3870NXYSH.2012.04.011 Primary Construction of the Electronic Medical Records for Patients with Liver Diseases Fang Qing et al Division ofClinicallmmunology, Tongji Hospital ofTongji Medical College, HUST, Wuhan, 430030 Abstract Objective: To construct an electronic medical recordssystem that could support clinical and research worksfor patients with chronic liver diseases. Methods: First,the demand analysis and structure design of database system were done. Then the systemical software was designed. Input medical records to test the function of the system so丘ware. Results: The database software was developed successfully, including input, storage , query, retrieval, output and basic statistical functions. With the high efficiency of medical records input, updated the personal clinical information data were realized. More than 4000 outpatients personal clinical information data accumulated in the past time were input and a large data base were built up. Conclusion: Electronic medical records play a key role in the combination between clinical pract;ce and research works. Key words Electronic Medical R