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为了推进现代化医院的信息化,网络化管理水平,适应日益提高的医院的临床工作效率和医疗服务质量管理,我院于1998年实施了“军字一号工程”(Hospital information system简称HIS),2000年我院运行了医师工作站1.46版,初步实现了信息化电子病案。该系统的顺利运行使临床医务人员从繁重的手工病案中解脱出来,提高临床工作效率和服务质量。该系统虽然方便快捷,但是具有可复制、可随意修改、缺乏对病案质量的自动监控等缺点。广州军区总医院开发了新的电子病案软件,较好地解决了这一问题。我院于2007年在保持原有医师工作站的功能和流程的基础上,实施了我院“医师工作站系统”的升级。新版医师工作站主要在原来电子病案的基础上,增加了对病历完成时限和病历内容的监控,以及对病历的评分系统,有效地促进了医疗管理水平的提高,规范临床病历、提高病案质量、减少医疗差错。
In order to promote the modernization of hospital information, network management level, to meet the ever-increasing hospital clinical work efficiency and medical service quality management, our hospital in 1998 implemented “military word system project ” (Hospital information system referred to as HIS ) In 2000, our hospital ran a physician workstation version 1.46, initially realizing the electronic medical records. The smooth operation of the system free clinicians from cumbersome manual medical records and improve clinical work efficiency and service quality. Although the system is convenient and quick, it has the defects of being copyable and freely modifiable, and lack of automatic monitoring of medical record quality. Guangzhou Military Region General Hospital developed a new electronic medical record software, a better solution to this problem. Our hospital in 2007 to maintain the original physician workstation functions and processes based on the implementation of our hospital “physician workstation system ” upgrade. Based on the original electronic medical record, the new version of the medical workstation adds the monitoring of medical record completion dates and medical record contents as well as the system of scoring medical records, effectively promoting the improvement of medical management, standardizing medical records, improving the quality of medical records and reducing Medical error.