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目的探索严重临床异常病例/事件监测的不同实现途径。方法基于HIS系统自动触发报告、人工触发替代自动触发和回顾性搜索途径,在杨浦区中心医院发热、呼吸道、肠道等门诊科室开展监测工作。结果 2014年1-8月基于HIS系统自动触发报告病例为0,人工触发替代报告84例,其中重症肺炎59例,出血性肠炎1例,异常病例24例;回顾性搜索发现98例,其中重症肺炎59例,3例发热伴皮疹监测病例,4例出血性肠炎病例,异常病例32例。经核实,所有病例最终均排除,未被判定为严重临床异常病例/事件。结论在诊疗信息电子化转变过程中可通过不同的途径开展监测工作,人工触发替代报告途径能够及时有效的发现相关病例,是后期在诊疗信息电子化转变中开展项目监测的主要方法。
Objective To explore different ways to monitor serious clinical abnormal cases / events. Methods Based on the HIS system automatic triggering report, manual triggering alternative automatic triggering and retrospective search approach, monitoring was performed in the outpatient departments of fever, respiratory tract and gut in Yangpu District Central Hospital. Results From January to August 2014, the number of reports of automatic triggering based on HIS system was 0 and 84 were reported by manual triggering. Among them, 59 cases of severe pneumonia, 1 case of hemorrhagic enteritis and 24 cases of abnormalities were retrospectively reviewed. Among them, 98 59 cases of pneumonia, 3 cases of fever with rash monitoring cases, 4 cases of hemorrhagic enteritis, abnormal cases in 32 cases. Upon verification, all cases were eventually excluded and were not judged to be serious clinical abnormalities / events. Conclusion Monitoring can be carried out in different ways during the electronic transformation of medical information. Manual triggering of alternative reporting channels can promptly and effectively find related cases, which is the main method of project monitoring in the later electronic transformation of medical information.