儿童专科医院电子病历系统建设的经验总结

摘要

目的：总结儿童专科电子病历升级改造项目在医院的具体实施情况。方法：分析住院电子病历用户特点，描述新住院电子病历系统的功能设置，针对项目实施过程中的问题及解决对策进行阐述。结果：在医务、病案、信息、临床的相互配合下，新住院电子病历系统成功上线。结论：儿童专科电子病历系统建设不仅是一个服务临床、辅助管理的信息系统解决方案的设计实现过程，更要在过程中着重体现专科疾病研究、规范诊疗行为、提高质控管理等方面的建设。%Objective: To summarize the experience on Electronic medical record system (EMR) upgrading and reconstruction project of Beijing Children' s Hospital. Methods: To analyze the characteristics of inpatient doctors, describe the achievements in the first phase of the project, and highlight the experience in solving the problems and difficulties during the construction. Results: The inpatient part of EMR upgrade project successfully implemented through the cooperation of relevant departments. Conclusion: The construction of EMR is not only an IT project, but also a system establishment which puts emphasis on collecting pediatric disease data, regulating medical behaviors, and improving the management of quality control.