共查询到20条相似文献,搜索用时 234 毫秒
1.
2.
目的:了解临床医师对电子病历书写的态度和行为现状以及电子病历管理和对医疗质量的认知等情况,为制定科学的电子病历管理方案提供借鉴。方法:选取两所2所三级甲等和2所三级乙等医院临床医师共计450名进行调查,采用问卷调查医师对电子病例相关知识(如临床医师对电子病例相关法规认知、电子病例监控对电子病历影响及电子病历优点等)的认知和需求。结果:临床医师电子病历总体书写现状调查显示,对于书写电子病历中相似的部分,48.7%(219例)的医师直接复制粘贴再修改;复制粘贴使用比率≥40%占76.7%(345例);电子病历书写出错原因主要为认为责任心不强(38.2%)和病历系统掌握不到位(29.6%);促进临床医师按要求写好病历的主要动力为法律证据(32.9%)和培养临床思维(49.1%);54.9%(247例)医师能对自己的病历进行经常检查;科室负责人对电子病历经常检查的占33.1%(149例);50%左右人员对电子病历系统操作掌握情况一般;79.33%的临床医师认为电子病历的使用有助于提高医疗质量;临床医师认为电子病历对医疗质量的影响主要是提高病历书写速率、病历完成及时性、管理系统性、病历安全性和患者满意度。结论:临床医师在电子病历书写中复制粘贴比例较高,且对相关的法律法规认识一般,对医院电子病历系统掌握不熟悉,应加大相关内容的培训,更有利于医院电子病历的管理。 相似文献
3.
4.
5.
抓住电子病历应用共享核心 推进数字化医院建设 总被引:1,自引:0,他引:1
国家卫生部对电子病历应用水平验收主要是对医院、区域电子病历共享进行验收,意在促进区域协同医疗和全民健康管理。长安医院紧紧抓住全国电子病历试点医院这一契机,努力建设数字化医院,获得国家卫生部“电子病历系统应用水平”考核全国第一,医院建设获得全面推进。 相似文献
6.
目的:通过整合302医院丰富的肝病病例、肝病专家诊疗经验和临床科研数据,建立肝病知识库,提高基础资源辅助临床诊疗和科研的能力。方法:对肝病智能知识模型进行分析,获取知识库中结构化知识,并以知识库模型的形式建立知识库,形成一套独立、可重复的智能化的辅助诊疗和科研信息系统,实现知识库辅助临床诊疗、知识科学研究,最大程度发挥知识库的意义,真正为临床服务。结果:建立的基于HIS的肝病知识库主要编配于医疗单位,适用于临床医护人员、临床科研人员以及所有从事医疗行业的工作人员。医护工作者可通过程序访问知识库,对知识库中的肝病知识进行检索、分析、推理,辅助临床医护工作者提高临床诊疗能力,提升临床科研水平。结论:建立的肝病知识库系统为用户提供横向及纵向医疗基础信息的检索、分析及推理方法。推理出的合适的知识模型,为肝病的临床诊疗和临床科研提供前沿、实用、高效的智能辅助信息支持。 相似文献
7.
电子病历是临床信息的集成平台,可以提供完整、安全、可交换、可挖掘的临床信息源,同时也可以改变传统的医疗质量监控与安全管理方式,提高质量和安全管理水平。介绍了基于电子病历的医疗质量控制与安全管理的一系列策略,主要包括数字化医疗质量监控管理平台、单病种临床路径管理系统、合理用药监测与处方点评系统、医疗过程控制与任务管理、危急值提醒与医疗安全警示、院内感染管理系统、重症病人监护管理系统、基于电子病历的无线移动技术和物联网技术的应用等。
相似文献8.
9.
目的 利用电子信息工程,创建一种新型、安全、高效的护理工作模式。方法 在医院未实现护理无线移动系统的状态下,研制在电子病历中实现护理电子病历、护理管理等7项综合功能,使医院电子病历“无纸化”办公得以施行。结果 简化医嘱查对制度和流程,杜绝执行转抄医嘱方面的护理差错,保证患者用药安全,缩短护士的非护理时间,减轻护士的工作量,推进护理工作信息改革进程。结论 对患者、护理人员、医生、护理管理和医院节省资金等方面均带来不同程序的收益,降低管理成本,提高管理效能,为护理科学化管理提供正确的方法和途径。 相似文献
10.
11.
ObjectivesTo compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks.DesignCross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems.Setting32 hospital units in 19 Norwegian hospitals with electronic medical records systems.Participants227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems.ResultsMost tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents'' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems.ConclusionsDoctors used electronic medical records systems for far fewer tasks than the systems supported.
What is already known on this topic
Electronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasksWhat this study adds
Doctors in Norwegian hospitals reported a low level of use of all electronic medical records systemsThe systems were mainly used for reading patient data, and doctors used the systems for less than half of the tasks for which the systems were functionalAnalyses of actual use of electronic medical records provide more information than user satisfaction or functionality of such records systems 相似文献12.
???????目的
研究与开发具有皮肤病专科特色的电子病历系统,以实现皮肤科病人医疗信息的采集、加工、存储、传输和服务。方法 以windows sqlserver2005为后台数据库,以XML、C#为开发语言,建立皮肤病结构化病历。结果 该系统运行良好,安全稳定、易维护、通用性好。有效地提高了医生书写病历的速度和质量,并具有皮疹数码照片嵌入等功能。结论 本研究实现了具有皮肤病专科特色的电子病历系统,值得皮肤病医院推荐使用。 相似文献
13.
Ray Jones Janne Pearson Sandra McGregor Alison J Cawsey Ann Barrett Neil Craig Jacqueline M Atkinson W Harper Gilmour Jim McEwen 《BMJ (Clinical research ed.)》1999,319(7219):1241-1247
ObjectiveTo compare the use and effect of a computer based information system for cancer patients that is personalised using each patient''s medical record with a system providing only general information and with information provided in booklets.DesignRandomised trial with three groups. Data collected at start of radiotherapy, one week later (when information provided), three weeks later, and three months later.Participants525 patients started radical radiotherapy; 438 completed follow up.InterventionsTwo groups were offered information via computer (personalised or general information, or both) with open access to computer thereafter; the third group was offered a selection of information booklets.OutcomesPatients'' views and preferences, use of computer and information, and psychological status; doctors'' perceptions; cost of interventions.ResultsMore patients offered the personalised information said that they had learnt something new, thought the information was relevant, used the computer again, and showed their computer printouts to others. There were no major differences in doctors'' perceptions of patients. More of the general computer group were anxious at three months. With an electronic patient record system, in the long run the personalised information system would cost no more than the general system. Full access to booklets cost twice as much as the general system.ConclusionsPatients preferred computer systems that provided information from their medical records to systems that just provided general information. This has implications for the design and implementation of electronic patient record systems and reliance on general sources of patient information. 相似文献
14.
Although patient confidentiality has been a fundamental ethical principle since the Hippocratic Oath, it is under increasing threat. The main area of confidentiality is patient records. Physicians must be able to store and dispose of medical records securely. Patients should be asked whether some information should be kept out of the record or withheld if information is released. Patient identity should be kept secret during peer review of medical records. Provincial legislation outlines circumstances in which confidential information must be divulged. Because of the "team approach" to care, hospital records may be seen by many health care and administrative personnel. All hospital workers must respect confidentiality, especially when giving out information about patients by telephone or to the media. Research based on medical-record review also creates challenges for confidentiality. Electronic technology and communications are potential major sources of breaches of confidentiality. Computer records must be carefully protected from casual browsing or from unauthorized access. Fax machines and cordless and cellular telephones can allow unauthorized people to see or overhear confidential information. Confidentiality is also a concern in clinical settings, including physicians'' offices and hospitals. Conversations among hospital personnel in elevators or public cafeterias can result in breaches of confidentiality. Patient confidentiality is a right that must be safeguarded by all health care personnel. 相似文献
15.
16.
17.
18.
19.
目的
对医院临床信息系统进行改造和完善,进行患者临床安全信息保障体系理论研究。方法 结合医院信息化实际,针对药品、护理、手术、检查、检验、输血六大类医嘱,分析其流转环节关键节点,进行信息闭环,研究护理执行文档、手术医疗器械以及消毒供应包管理追溯、医技报告危急值报警等信息标准化,建立数据集,实现病人临床安全的信息化支撑。结果 实现了护理文档数据标准化和移动护理数据采集的全面应用,探索了医嘱闭环信息的工程化建设方法,研发了移动护理软件,形成了护理工作绩效评价的新模式。结论 通过项目研究,在国内率先进行了护理文档标准化研究,形成了医嘱闭环执行与护士工作量评价新方法,并在患者临床安全的一系列关键环节进行了信息保障的全面应用。 相似文献
20.
《International journal of bio-medical computing》1983,14(5):365-368
A computerised medical records system for diabetic patients has been developed on a Vector Graphics MZ microcomputer using programs written in UCSD-Pascal. The system allows addition or deletion of patient records, alteration of records, alphabetical listing of recorded patients' names, and printing of individual records in a concise format. The amount of information capable of being stored in each record makes the easy to use system a useful device in the clinical management of diabetic patients. 相似文献