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医院信息系统中化疗药物医嘱管理模块的开发与应用
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| 篇名： | 医院信息系统中化疗药物医嘱管理模块的开发与应用 |
| TITLE： | |
| 摘要： | 目的：促进化疗药物医嘱开具的规范化、合理化，提高化疗药物临床使用的安全性。方法：通过开展相关现状调查工作，确定在医院信息系统（HIS）中设计化疗药物医嘱管理模块时应涉及和考虑的因素和信息；规范并确定医嘱开具时参考的标准化疗方案，我院维护基础数据、设定菜单，基于HIS拓展设计患者信息自动导入、药物及治疗方案选择、警示等功能，实现化疗药物医嘱管理模块在HIS中的对接和有效应用；通过统计模块运行后2年内每月化疗药物医嘱不合理率，评价其应用效果。结果与结论：我院开发的化疗药物医嘱管理模块能够实现医师授权管理、自动导入患者相关信息、预置化疗方案以方便医师录入与选择等功能；该模块运行后，不合理化疗药物医嘱从初期（2014年6月）的28条（1.15％）下降至2年后（2016年6月）的4条（0.14％）。规范了化疗药物医嘱开具过程，并初步实现了信息化管理，提高了医嘱录入效率及准确性，为规范医师诊疗行为和规避医院风险提供了保障和支持，促进了化疗药物的正确、安全、合理使用。 |
| ABSTRACT： | OBJECTIVE： To promote the standardization and rationality of medical order for chemotherapeutic drugs， and improve its safety use in clinic. METHODS： Through developing the investigation of relevant status quo， the design factors and information that should be involved and considered of the medical order management module for chemotherapeutical drugs in hospitalized information system（HIS） were determined. The reference standard chemotherapy regimen used in medical orders was put forward. The basic data was maintained and menu setting was conducted. Based on HIS， the function module of automatically importing patients’ information， drug and program selection， warning were designed； the docking and effective application of medical order management module for chemotherapeutical drugs in hospital medical order management information system was achieved. Its application effects were evaluated by summarizing monthly irrational rate of medical orders within 2 years. RESULTS & CONCLUSIONS： The medical order management module for chemotherapeutical drugs developed in our hospital can achieve physician authorized management， automatically importing patient-related information， preservative chemotherapy regimen for easy entry and selection. The irrational numbers of chemotherapy orders were decreased from 28 orders （1.15％） in prime （Jun. 2014） to 4 orders （0.14％） 2 years later （Jun. 2016）. Procedures of medical orders for chemotherapeutical drugs are standardized， initially realize information management， improve input efficiency and accuracy of medical orders， which have provided protection and support for standardizing physicians’ diagnosis and treatment behavior and avoiding the hospital risk， and promote correct， safe and rational use of chemotherapeutic drugs. |
| 期刊： | 2017年第28卷第19期 |
| 作者： | 王钰博，王捷，李东锋，肖明森，张华，王建华 |
| AUTHORS： | WANG Yubo，WANG Jie，LI Dongfeng，XIAO Mingsen，ZHANG Hua，WANG Jianhua |
| 关键字： | 化疗药物；医嘱管理；医院信息系统；模块；开发；应用；医嘱不合理率 |
| KEYWORDS： | Chemotherapeutic drugs； Medical order management； Hospitalized information system； Module； Development； Application； Irrational rate of medical orders |
| 阅读数： | 479 次 |
| 本月下载数： | 11 次 |
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