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病案首页是对住院患者医疗数据汇总分析的重要数据源,传统医师手工填写病案首页耗时过长,不利于医师从事专业活动、且手工填写项目过多造成病案首页数据不准确不利于信息利用。某医院分析病案首页数据的自动采集的数据源、对可采集的病案首页数据内容进行自动采集、采用逻辑校对提高病案首页的逻辑性等三方面的工作,通过升级医院的信息系统,疏通医院患者信息的传输通道、将医院内不同的系统数据进行对接,从门诊系统、医技系统、电子病历、护理记录等多个系统采集病案首页的各类所需的数据信息,从逻辑关系上控制病案首页相应内容的填写。从数据采集上减少医师填写病案首页的内容、从逻辑关系审查上提高病案首页的填写质量,达到病案首页智能化填写的效果。
The first page of the medical record is an important data source for the summary analysis of the medical data of the inpatient patients. Traditional physicians manually fill in the first page of the medical record for too long, which is not conducive to the professional activities of the physician. A hospital analyzes the data source of the first page of the medical records and automatically collects the data of the first page of the medical records that can be collected, and uses logic collation to improve the logistic of the first page of medical records. By upgrading the hospital’s information system and unblocking the patients Information transmission channel, the hospital system of different docking data from the outpatient system, medical technology systems, electronic medical records, nursing records and other systems to collect all kinds of medical records on the front page of the various types of data required to control the medical records from the logical case Fill in the corresponding content From the data collection to reduce physicians fill out the contents of the first page of the medical record, improve the quality of the first page of the medical record from the logical relationship review, and achieve the effect of filling the first page of the medical record intelligently.