【作者】 彭丽玲；

【导师】 秦树人；

【作者基本信息】 重庆大学 ， 环境工程， 2003， 硕士

【摘要】 病案管理是医院管理的重要环节，开发病案管理系统是医院现代化建设过程中必须迈出的重要一步，因此研究病案管理系统具有深远意义。本文从虚拟式医电仪器对病案信息的存储要求着手，开始对病案管理系统的研究。首先介绍了病案管理系统的构成 、功能模块、与医院信息系统的关系、技术基础以及病案管理系统所遵循的标准和相应技术，然后介绍了基于虚拟仪器技术的虚拟式医电仪器的形成、功能实现、虚拟式医电仪器库的形成和拼搭式虚拟医电仪器的形成。接着阐述了在虚拟式医电仪器尤其是虚拟式脑电图仪中开发病案管理系统的意义、必要性，并开发了用于虚拟式脑电图仪的病案管理系统，实现了脑电图仪中病案信息的添加、修改、删除、检索等功能。同时，本文在研究病案管理系统的国内外现状时发现，目前国内的病案管理方式已嫌陈旧，难于满足医疗体制改革所提出的要求，同国外的现状相比也有较大差距。因此，本文对病案管理系统进行了进一步的研究与开发。本文对目前国际上广泛使用的HL7标准在病案管理系统中的应用做了一些研究，并按照卫生部2002年5月28日印发的《医院信息系统基本功能规范》 （卫办发［2002］116号）中对病案管理系统范围的界定，开发了在数据类型上遵循HL7标准的病案管理系统，实现了住院病案的首页录入、病案检索、病案借阅管理、多种统计等功能。本文按照开发管理信息系统的步骤，从病案管理系统分析 、 系统设计、系统开发三步对该系统进行阐述。最后，本文从全息病案管理、和医院信息系统的连接、信息的海量存储三方面谈论了本病案管理系统的进一步发展方向。更多还原

【Abstract】 Managing medical records well is important for a hospital. Especially in the process of hospitals’ modernization, being provided with a finer medical records management system (MRMS) to manage medical records is a very important step. So it is significant to make researches on medical records management system. In this paper, the research on medical records management system is begun from the storage need of medical records in visual medical electronic instrument. Firstly, the constitute, the function, the connection between MRMS and hospital information system (HIS), the technology based and the standard followed by MRMS are introduced. Secondly, the structure, the function of visual medical electronic instrument based on visual instrument technology, the process of building a visual medical electronic instrument bank and of forming a build-up visual medical electronic instrument are narrated. Then the paper introduces the inevitability and the significant of developing MRMS in a visual medical electronic instrument, especially in a visual electroencephalograph (EEG). Grounding on these theories and technology, we develop a MRMS that is fit for visual EEG system, which has functions of adding medical records, updating, deleting and recalling information. In the course of studying actualities of MRMS in the world, we found that the method of managing medical information currently used at home has already not been suitable for the evolution of medical care system, and MRMS available, which dropping behind those used overseas, are holding back the evolvement of medical information management mode. Therefore, it is essential to carry out farther research and develop for MRMS. In this paper, we try to adopt the HL7 standard that is generally employed to design database for MRMS on the side of data type. We also make the system conform to the foundational criterion stipulated for MRMS in the HIS by Chinese Ministry of health in May.28, 2002. The MRMS we developed performs functions of saving content of medical records’ First Page, recalling medical information, managing information generated in the course of learning and returning, taking statistics according to key word and so on. In the paper, the three steps of system analysis, system designing and system development, which usually are applied to develop management information system, are expounded. At last, three sides will be carried on in future are mentioned, which are to manage<WP=6>integrated information for medical records, to connect with HIS, to select storage technology for a mass of information.更多还原