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目的 :探索和建立耳鼻咽喉科病历的计算机管理系统。方法 :在PentiumCeleron 333计算机上安装MicrosoftOffice 97软件 (包括Word和Excel两部分 ) ,开发研制本管理系统 ,并应用EPSON LQ16 0 0K针式打印机打印输出病历。整个电子病历系统包括住院病案、术前谈话、手术记录、出院记录等 4部分和内容详尽的病历索引文件 ,收录了 6 0多种耳鼻咽喉科常见疾病的样板病史。在索引文件中查找最符合新收病例样板病史的同时 ,又将新写病历的关键资料添加到病历数据库中 ,便于今后的科研统计工作。根据实际收治患者的病史特点 ,对检出的样板病史中某些细节进行“有或无”式的修改 ,就能够得到一份内容详尽 ,格式规范 ,且具有个性化的病史。由于精确地设置了所需打印内容的字体和行距 ,每份病案都能准确地打印在相应的空格和横线上。结果 :电子病历内容完整详尽 ,无错误 ,遗漏 ,病案的格式规范 ,字迹清晰 ,提高了病案书写质量和医师的工作效率和工作质量。结论 :由于电子病历具有多种永久保存形式 ,提高了住院病案的管理质量
Objectives: To explore and establish a computerized management system for otolaryngology records. Methods: Microsoft Office 97 software (including Word and Excel) was installed on the PentiumCeleron 333 computer. The management system was developed and printed out using the EPSON LQ1600K stylus printer. The entire electronic medical records system includes in-patient medical records, preoperative conversations, surgical records, discharge records and other four parts and a detailed medical records index file containing over 60 common diseases of otolaryngology sample history. In the index file to find the most consistent with the history of the newly received case model at the same time, the new key records of medical records will be added to the medical records database for future scientific research and statistics. According to the characteristics of the actual treatment of patients with history, some of the details of the history of the sample plate to detect the “with or without” type of modification, you can get a detailed, standardized format, and a personalized medical history. Due to the precise setting of the font and line spacing of the desired print, each medical record can be accurately printed on the appropriate white space and horizontal lines. Results: The contents of EHR were complete and complete, no errors and omissions, normative format of medical records, and clear writing, which improved the quality of medical records writing and physicians’ work efficiency and work quality. Conclusion: As electronic medical records have a variety of permanent preservation forms, improving the quality of management of inpatient medical records