電子病歷在專病門診建設中的價值及應用

張董曉 賈楠 馬紅玉

[摘要] 專病門診就是近年來迅速發展的一種門診服務模式，電子病歷具有樣本量大、更符合臨床實際等諸多優點。模式化電子病歷和專病門診相結合可定向整理收集某一專病病例，對專病療效提升、新藥研發等多方面具有重要意義。本文以首都醫科大學附屬北京中醫醫院乳腺科漿細胞性乳腺炎專病門診為例，探討電子病歷在專病門診建設中的價值及應用。從專病門診電子病歷的模板設計及操作流程及應用效果兩方面進行闡述，發現專病門診中的電子病歷可有效形成高質量專病臨床數據集;提高對疾病認知水平，未病先防;形成臨床決策;優化臨床路徑;為教學提高豐富素材，提高教學水平。電子病歷的累積對專病門診的建設起到重要的作用，是提升學科實力的重要途徑。

[關鍵詞] 電子病歷;專病門診;學科建設

[中圖分類號] R197.323;R659? ? ? ? ? [文獻標識碼] A? ? ? ? ? [文章編號] 1673-7210（2020）02（c）-0174-04

[Abstract] Disease-oriented outpatient clinic is a rapidly developing outpatient service mode in recent years. Electronic medical record has many advantages， such as large sample size， more in line with clinical practice and so on. The combination of the model electronic medical record and the disease-oriented outpatient clinic can be used to collect a specific disease case， which is of great significance to the improvement of the special disease efficacy and development of new drugs. This paper discusses the value and application of electronic medical record in the construction of disease-oriented outpatient clinic， taking the plasma cell mastitis of galactophore department of Beijing Traditional Chinese Medicine Hospital， Capital Medical University as an example. From the two aspects of the template design， operation process and application effect of the electronic medical record in the disease-oriented outpatient clinic. It is found that the electronic medical record in the disease-oriented outpatient clinic can effectively form a high-quality clinical data set of specific diseases. To improve the level of disease awareness， prevent diseases before they occur; form clinical decision-making; optimize the clinical pathway; enrich materials for teaching and improve the teaching level. The accumulation of electronic medical records plays an important role in the construction of disease-oriented outpatient clinic and is an important way to enhance the strength of the discipline.

[Key words] Electronic medical records; Disease-oriented outpatient clinic; Discipline construction

為滿足群眾個性化、高標準的醫療服務需求，近年來國內各大醫院紛紛進行了以患者需求為導向的門診診療模式創新[1]。專病門診就是近年來迅速發展的一種門診服務模式，它是指按某種疾病或癥狀名稱命名的門診，由對此疾病學有專長的醫生坐診或參與的門診[2]，如高血壓專病門診、肺炎專病門診等。專病門診不僅方便了患者就診，對積累專病病例、提升醫療水平也有很大意義。傳統的手工書寫有很多弊端，如病例資料書寫后都交給患者，醫生無法保存，記錄內容不規范、缺項、字體不易辨認等[3]。……