解放军总医院急诊专科系统的设计与实现-中国数字医学.PDFVIP

系统研发与设计 System Development and Design 解放军总医院急诊专科系统的设计与实现 季磊① 薛万国① 刘敏超① 摘 要 目的：解决急诊抢救留观区手工操作问题，实现全流程数字化管理，提高医生、护士的工作效率。方法：分析急诊 现存问题，梳理急诊工作流程，形成集成方案和架构设计。结果：规范了急诊信息流程，实现了一套急诊信息系统，能够管 理患者从入院到出院的整个流程。结论：为国内急诊抢救留观建立了一个新的样板系统。 关键词　急诊抢救和留观 电子病历 系统集成 Doi:10.3969/j.issn.1673-7571.2016.03.012 [中图分类号] R823;R319 [文献标识码] A Design and Implementation of Emergency Management System about PLA General Hospital / JI Lei, XUE Wan-guo, LIU Min- chao//China Digital Medicine.-2016 11(3): 36 to 38 Abstract Objective: A digital management system specifically designed for emergency treatment and observation is a pressing need which aims to manage medical records, orders and billing for both doctors and nurses. Methods: Key problems in emergency were listed and the work process was combed to help us form integration scheme and design system architecture. Results: The emergency workflow standards were built and a new system was implemented which manages the whole process of patient admission, treatment and discharge. Conclusion: The system is specifically designed for emergency and maybe a new example of emergency management system in China. Keywords emergency treatment and observation, electronic medical records, system integration Corresponding author Computer Department of PLA General Hospital, Beijing 100853, P.R.C. 1 引言 国内医院的急诊一般归属于门诊管理，但急诊的业务流程与普通门诊有很大区别。特别是急诊抢救和留观区，兼具门 诊和住院管理的特点，常规的门诊工作站和住院工作站都不能很好地满足日常工作需求。在此区域，患者周转速度快，病 [1] 历和医嘱有特殊的书写规定，迫切需要量身定做的信息系统 。 解放军总医院急诊科是一个比较典型和复杂的案例，整个科室划分为七个区域：流水区、发热门诊、输液区、抢救 间、留观区、病房和监护室。从收治对象看，流水、发热和输液面向门诊患者，病房和监护室面向住院患者，抢救和留观 区面向门诊患者但兼具住院特征：患者挂号就诊，但收治入科后，医生开医嘱、写病历，护士执行医嘱、写护理记录、配 液、计价，这些工作都类似病房业务，出院前由门诊收费结算，简言之，患者的入院和出院依据门诊规范，中间的诊疗类 似住院流程。对于抢救和留观区，无论是门诊工作站还是住院工作站都无法支持整个业务流程：单独使用门诊系统无法解 决医嘱、药品配送、病历、自动划价问题，单独使用住院系统无法解决患者属性、病案、结算等问题。直至2014年，急诊 还在手写医嘱、病历、护理记录，患者为用药奔波于诊区、门诊收费、药房之间。 近年来，急诊科考察了一些大型