口腔电子病历系统中临床路径管理的实现和探讨

摘要

许多医院对于电子病历中整合临床路径管理缺乏认识，往往是把电子病历和临床路径孤立存在，将临床路径的实施当作一项任务完成。目前大多数医院仍采用传统纸质形式实施的临床路径，其结果是大大降低了临床路径的管理作用。根据临床路径相关规范要求设计了临床路径子系统。系统整合电子病历功能，使医生在书写电子病历时，自动进行临床路径关联，使病历书写、入径表单录入一步完成，实现标准化和规范化的疾病诊疗计划，从而既提高了电子病历的质量又大大增强了临床路径的管理力度。同时对优化和完善该系统的问题进行了探讨。%Many hospital lack of awareness the clinical path management in the integration of electronic medical records, not only often isolate the electronic medical records and the clinical pathways, but also take the implementation of clinical pathways as a task. Currently most hospital still use traditional paper forms to implement the clinical pathways. The result is greatly reduced the management role of the clinical pathways. This topic designed the clinical path subsystem according to the relevant regulatory requirements. The EMR's functionality is integrated into the system, so it will associate the clinic pathways automatically when doctors write the electronic medical records, which make the medical writing and the path form entry one step, and achieve the standardization and normalization of disease diagnosis and treatment plan, thereby it both improves the quality of electronic medical records and significantly enhances the management of clinical pathways. Finally this paper also explores the problems to optimize and complete the system.