摘要
某院在门急诊诊疗记录中只有门急诊病历、就诊处方、治疗处置记录、护理记录、检查记录、知情告知信息,缺门急诊诊断证明书记录,为实现其诊断活动记录完整,在门诊电子病历HIS系统现有数据元中,设计并嵌入门急诊诊断证明书相关的业务活动及活动记录,包括基本内容、基础模板、架构图、临床文档数据组分类与代码、相关业务活动记录分类、临床文档基础模板分别对应嵌入门(急)诊诊疗记录中,实现门(急)诊疾病诊断证明信息化管理。
In the outpatient and emergency diagnosis and treatment record,following the basic frame of electronic medical record and date standard,there is only outpatient and emergency medical record,prescription,treatment record,nursing record,checking record and informed information,without outpatient and emergency diagnosis certificate record.To make the diagnosis activity fully recorded,based on existing data elements in HIS system for outpatient and emergency electronic medical record management,the related diagnosis activities and activity records for outpatient and emergency ICD and TCD disease diagnosis certificate are embedded.The design for embedding all into outpatient and emergency medical record is made,including the basic content,template,framework,classification of clinical document data sets and codes,related diagnosis activity record classification and the basic template for clinical documentation.It provides a clinical evidence-based path for medical documents checking and the revision of electronic medical record industry standards.
作者
王东霞
谭仁琼
曾霞
李晶
贺世春
冉炼志
张先祥
Wang Dongxia;Tan Renqiong;Zeng Xia;Li Jing;He Shichun;Ran Lianzhi;Zhang Xianxiang(Chongqing Three Gorges Central Hospital,Chongqing 404000,China)
出处
《中国病案》
2019年第10期47-48,112,共3页
Chinese Medical Record
基金
社会事业与民生保障科技创新项目(WZSTC-2017016)
关键词
门诊疾病诊断证明书
电子病历
嵌入
设计
Outpatient disease diagnose certificate
Electronic medical record
Embed
Design
