【摘要】 目的探讨电子病历为基础的临床医疗文书的建构,通过使用设计电子诊断证明代替目前手工填写门诊疾病诊断证明,实现门诊疾病诊断证明与电子病历信息共享,规范门诊出具疾病诊断证明管理。方法观察组使用电子诊断证明,以设计电子诊断证明模版、五个二的安全管理即两个告知、两个编码号、两个签名、两个核对、两处手填写措施,将电子诊断证明模版放在电子病历医疗文书中提供医师使用;对照组使用手工填写门诊疾病诊断证明,采取传统常规管理,统一印刷门诊疾病诊断证明提供使用。比较两组医师出具门诊疾病诊断证明合格率,使用统计学软件对合格证明与不合格证明数据进行统计分析。结果观察组与对照组出具门诊疾病诊断证明合格率分别为97.58%、82.26%,出具合格证明与不合格证明数据经统计软件分析,χ2=196.61、P=1.15E-44、P<0.05,具有统计学显著性差异。结论电子诊断证明代替手工填写门诊疾病诊断证明,实现电子诊断证明与电子病历信息共享,完善门诊出具疾病诊断证明医疗文书规范管理。?更多还原

【Abstract】 Objectives To investigate the establishment of clinical medical document based on electronic medical records,achieve information sharing for electronic diagnosis certificates and electronic medical records through applying electronic diagnosis certificate instead of the hand-written diagnosis certificate,thus to standardize the management for issuing diagnosis certificates in the outpatient department.Methods Designed for secure management including two notifications,two management code number,two signatures,two check,two hand-written measures,the template of electronic diagnosis certificate,were embedded in the electronic medical record for doctors by the observation group,while the traditional general management was taken by the control group.By hand writing,they fill the diagnosis certificates printed in a unified format with paper.The qualified rate for issuing clinical diagnosis certificates by the two groups could be accessed.The statistical analysis on the qualified and unqualified was made by statistical software.Results The qualified rates for issuing clinical diagnosis certificates by the two groups were 97.58% and 82.26% respectively.The statistical analysis showed χ2=196.61,P =1.15E-44,P<0.05,which had significant difference in statistics.Conclusions We should substitute for the hand-writtendiagnosis certificate by the electronic diagnosis certificated,achieve information sharing for E-diagnosis certificates and E-medical records and standardize the management for issuing diagnosis certificates as medical documents in the outpatient department.更多还原