武汉市某三甲医院肝病专科电子病历系统的初步建立

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.%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 software. 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 practice and research works.