以围术期电子病历为核心的临床麻醉信息系统及其集成-中国数字医学.PDFVIP

系统研发与应用 System Research and Application 以围术期电子病历为核心的临床麻醉信息系统及其集成 ① ＊ ① 王文翠 詹永丰 李亚东 摘 要 作为临床信息系统的重要组成部分，临床麻醉信息系统（CAIS）在医院的临床实践中得到了广泛的应用。沈阳军区 总医院建立了以病人为中心、以围术期电子病历为核心的CAIS，实现与医院相关系统的有效集成，对手术麻醉相关信息实现 全数字化管理，进而提高手麻工作效率和质量、为质量控制、科室管理和科研工作提供数据支持。介绍了CAIS的基本工作流 程，分析了与医院相关系统之间的集成技术。 关键词 临床麻醉信息系统 围术期电子病历 集成 Doi:10.3969/j.issn.1673-7571.2014.02.015 Clinical Anesthesia Information System Based on Perioperative Period Electronic Medical Records and Its Integration / WANG Wen-cui, ZHAN Yong-feng, LI Ya-dong//China Digital Medicine.-2014 9(2): 43 to 45 Abstract As one of the critical parts of clinical information system, clinical anesthesia information system now is widespread in clinical practice. A patient-centeredness and electronic medical records in Perioperative Period based clinical anesthesia information system was established and integrated with other systems perfectly to achieve the full digital management of anesthesia process. Clinical anesthesia information system holds the promise of increasing working efficiency, improving medical quality, providing data to meet the requirements of quality control, management of department and scientific research. The basic work flow of clinical anesthesia information system was introduced first, and then the integration with other systems was analyzed in the paper. Keywords clinical anesthesia information system, perioperative period electronic medical records, integration Corresponding author Director of Information Department, the General Hospital of Shenyang Military Region, Shenyang 110840, Liaoning Province, P.R.C. 1 引言 目前，我国医院的信息化建设已经进入以电子病历为核心的临床信息系统阶段，围术期电子病历作为完整电子病历的 重要组成部分，临床麻醉信息系统的普及应用势在必行。我院重点建立了围绕病人诊疗，以围术期电子病历为核心的临床 麻醉信息系统[1] ，实现与医院