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许多医院对于电子病历中整合临床路径管理缺乏认识,往往是把电子病历和临床路径孤立存在,将临床路径的实施当作一项任务完成。目前大多数医院仍采用传统纸质形式实施的临床路径,其结果是大大降低了临床路径的管理作用。根据临床路径相关规范要求设计了临床路径子系统。系统整合电子病历功能,使医生在书写电子病历时,自动进行临床路径关联,使病历书写、入径表单录入一步完成,实现标准化和规范化的疾病诊疗计划,从而既提高了电子病历的质量又大大增强了临床路径的管理力度。同时对优化和完善该系统的问题进行了探讨。
In many hospitals, the lack of awareness of integrated clinical pathway management in EHRs often exists in isolation from electronic medical records and clinical pathways, and the implementation of the clinical pathway is considered as a task to be completed. At present, most hospitals still use the traditional paper form of the implementation of the clinical path, the result is greatly reduced the clinical path management. The clinical pathway subsystem was designed according to the relevant normative requirements of clinical pathway. The system integrates the electronic medical record function so that when the physician writes the electronic medical records, it automatically correlates the clinical pathways so that the medical record writing and entry form entry are completed in one step, and the standardized and standardized disease diagnosis and treatment plan is realized, so that the quality of the electronic medical records is greatly improved Enhance the management of clinical pathways. At the same time, the problems of optimizing and perfecting the system are discussed.