CN105809599A - Emergency medical information system - Google Patents
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Abstract
本发明涉及医疗信息技术领域，尤其涉及一种急诊医疗信息系统，用以有效提高急诊医护工作效率、服务质量并规范和提高医护人员的专业行为以及优化急诊资源的配置。至少包括：急诊预检分诊信息模块、急诊抢救信息模块、急诊输液留观信息模块、急诊发热门诊信息模块、急诊交班信息模块，因此，该系统以急诊病人的完整救治过程为主线，能够实现全流程、全方位地追踪和监控医疗护理过程。
The present invention relates to the field of medical information technology, and in particular to an emergency medical information system, which is used to effectively improve the work efficiency and service quality of emergency medical staff, standardize and improve the professional behavior of medical staff, and optimize the allocation of emergency medical resources. At least include: emergency pre-examination and triage information module, emergency rescue information module, emergency infusion observation information module, emergency fever clinic information module, emergency shift information module, therefore, the system takes the complete treatment process of emergency patients as the main line, and can realize The whole process and all-round tracking and monitoring of medical care process.
Description
技术领域technical field
本发明涉及医疗信息技术领域，尤其涉及一种急诊医疗信息系统。The invention relates to the technical field of medical information, in particular to an emergency medical information system.
背景技术Background technique
现代急救医学已发展为集治疗抢救、医疗转诊、技术指导等为一体的重要医学门类。它主要解决对急、危、重症病人实行一站式急救医疗服务。近年来城市综合医院的急诊需求呈上升趋势，急诊医学的水平在一定程度上反映了一所医院的综合实力，甚至一个国家临床医学的总体水平。目前，存在有限的医疗资源已无法满足急诊患者日益增长的需求的情况。因此，从根本上改善医疗护理服务水平需要在增加医疗急诊物质人力资源的同时，引进科学的管理模式，优化急诊资源的配置，进行急诊信息化建设。Modern emergency medicine has developed into an important medical category integrating treatment and rescue, medical referral, and technical guidance. It mainly solves the one-stop emergency medical service for urgent, critical and severe patients. In recent years, the demand for emergency services in urban general hospitals has been on the rise. The level of emergency medicine reflects the comprehensive strength of a hospital to a certain extent, and even the overall level of clinical medicine in a country. Currently, there are situations where limited medical resources can no longer meet the increasing demands of emergency patients. Therefore, to fundamentally improve the level of medical care services, it is necessary to increase the material and human resources of medical emergencies, introduce scientific management models, optimize the allocation of emergency resources, and carry out emergency information construction.
医院目前已经具备比较完善的管理信息系统和临床信息系统，很好地支撑了门诊、住院等医疗业务的开展。但是由于急诊科的特殊性，使得它与医院其他各科具有显著不同的特点，例如，急诊科病人流转速度快，病情复杂多变，诊断不明确等。这就要求急诊科的医护人员提高工作效率的同时，也要保证工作质量，快速、准确、有效地对来诊患者进行诊治。随着急诊科的迅速发展，以及急诊工作效率要求和质控要求的进一步提高，由现有的门急诊工作站支撑的急诊信息化流程，虽然能够一定程度上解决一些问题，但难以满足急诊目前日益繁重的接诊工作和未来发展的需要。The hospital currently has a relatively complete management information system and clinical information system, which well supports the development of medical services such as outpatient services and inpatient services. However, due to the particularity of the emergency department, it has significantly different characteristics from other departments of the hospital. For example, the emergency department has a fast flow of patients, complex and changeable conditions, and unclear diagnosis. This requires the medical staff in the emergency department to improve work efficiency, but also to ensure the quality of work, and to diagnose and treat patients quickly, accurately and effectively. With the rapid development of the emergency department and the further improvement of emergency work efficiency and quality control requirements, although the emergency information process supported by the existing outpatient and emergency workstations can solve some problems to a certain extent, it is difficult to meet the needs of the emergency department. Heavy reception work and future development needs.
发明内容Contents of the invention
本发明的目的是提供一种急诊医疗信息系统，用以有效提高急诊工作效率和服务质量。The purpose of the present invention is to provide an emergency medical information system to effectively improve emergency work efficiency and service quality.
本发明的目的是通过以下技术方案实现的：The purpose of the present invention is achieved through the following technical solutions:
一种急诊医疗信息系统，至少包括：急诊预检分诊信息模块、急诊抢救信息模块、急诊输液留观信息模块、急诊发热门诊信息模块、急诊交班信息模块；其中，An emergency medical information system, at least including: an emergency pre-examination and triage information module, an emergency rescue information module, an emergency infusion observation information module, an emergency fever clinic information module, and an emergency shift information module; wherein,
所述急诊预检分诊信息模块，用于记录每个急诊病人的身份信息，并提取每个急症病人的生命体征信息，以及记录分诊护士根据每个急诊病人的生命体征信息为该急诊病人分配的就诊医生和病区；The emergency pre-examination and triage information module is used to record the identity information of each emergency patient, and extract the vital sign information of each emergency patient, and record that the triage nurse provides information for the emergency patient according to the vital sign information of each emergency patient. Assigned visiting physician and ward;
所述急诊抢救信息模块，用于记录针对每个急诊病人在抢救区的诊疗信息；The emergency rescue information module is used to record the diagnosis and treatment information for each emergency patient in the rescue area;
所述急诊输液留观信息模块，用于记录每个输液留观的急诊病人在输液留观区的诊疗信息；The emergency infusion observation information module is used to record the diagnosis and treatment information of each infusion observation emergency patient in the infusion observation area;
所述急诊发热门诊信息模块，用于记录各种传染病病原检查项目的检查结果，并对确诊的传染病进行上报；The emergency fever clinic information module is used to record the inspection results of various infectious disease pathogen inspection items, and report the confirmed infectious diseases;
所述急诊交班信息模块，用于收集每个急诊病人在所述抢救区和所述输液留观区的诊疗信息。The emergency shift information module is used to collect the diagnosis and treatment information of each emergency patient in the rescue area and the infusion observation area.
可选的，记录分诊护士根据第i个急诊病人的生命体征信息为所述第i个急诊病人安排就诊医生和病区时，所述急诊预检分诊信息模块，具体用于：Optionally, when the triage nurse arranges a doctor and ward for the i-th emergency patient according to the vital sign information of the i-th emergency patient, the emergency pre-examination triage information module is specifically used for:
记录所述分诊护士根据所述第i个急诊病人的生命体征信息参照预设的病情评分标准对所述急诊病人的病情的评分，并记录所述分诊护士根据评分结果为所述急诊病人安排的就诊医生和病区。Recording the scoring of the emergency patient's condition by the triage nurse according to the vital sign information of the ith emergency patient with reference to the preset condition scoring standard, and recording the score of the emergency patient by the triage nurse according to the scoring result Arranged visiting physician and ward.
可选的，所述急诊预检分诊信息模块，还用于：Optionally, the emergency pre-examination and triage information module is also used for:
针对患有预设疾病急诊病人预置对应的预设就诊医生和对应的预设病区。For emergency patients with preset diseases, the corresponding preset doctors and corresponding preset wards are preset.
可选的，所述急诊预检分诊信息模块，还用于：Optionally, the emergency pre-examination and triage information module is also used for:
记录每个分诊护士的工作量，以及根据各个就诊医生和各个病区负责人的反馈对每个分诊护士的工作准确性作出的评价。The workload of each triage nurse was recorded, and the evaluation of each triage nurse's work accuracy was made based on the feedback from each visiting doctor and each ward head.
可选的，所述急诊抢救信息模块，至少包括：Optionally, the emergency rescue information module at least includes:
申请提交单元，用于提交每个急诊病人的医疗行为申请；The application submission unit is used to submit the medical behavior application for each emergency patient;
急诊医嘱单元，用于至少收集每个急诊病人的检查化验结果、预设生命体征信息和/或会诊意见，记录每个就诊医生根据收集到的信息做出的医嘱；The emergency doctor's order unit is used to at least collect the inspection and test results, preset vital sign information and/or consultation opinions of each emergency patient, and record the doctor's order made by each doctor based on the collected information;
急诊电子病历单元，用于根据预设的电子病历模板，结合每个急诊病人的医嘱和处方，生成对应每个急诊病人的电子病历；The emergency electronic medical record unit is used to generate an electronic medical record corresponding to each emergency patient according to the preset electronic medical record template, combined with the doctor's order and prescription of each emergency patient;
危机告警单元，用于监控每个急诊病人的检查化验结果，在确定任一急诊病人的检查化验结果不满足预设要求时，通知值班医生。The crisis alarm unit is used to monitor the examination and test results of each emergency patient, and notify the doctor on duty when it is determined that the examination and test results of any emergency patient do not meet the preset requirements.
计价管理单元，用于提取每个急诊病人在抢救间产生的各项费用，输出第一结算结果。The pricing management unit is used to extract various expenses incurred by each emergency patient in the rescue room, and output the first settlement result.
可选的，所述申请提交单元，具体用于：Optionally, the application submission unit is specifically used for:
提交每个急诊病人的会诊申请，以及记录每个急诊病人的当前会诊状态和会诊意见；Submit the consultation application for each emergency patient, and record the current consultation status and consultation opinions of each emergency patient;
和/或，提交每个急诊病人的检验和影像检查的申请，以及记录每个急诊病人当前申请的检验和影像检查结果和以往的检验和影像检查结果，以及与现有医院信息系统进行数据共享；And/or, Submit requests for testing and imaging for each ED patient, and record current and past testing and imaging results for each ED patient, and share data with existing hospital information systems ;
和/或提交发热急诊病人的传染病病原检查项目的申请。And/or submit an application for inspection items of infectious disease pathogens for emergency patients with fever.
可选的，所述急诊医嘱单元，还用于：Optionally, the emergency medical order unit is also used for:
设置预设疾病医嘱套餐，记录所述就诊医生根据所述预设疾病的医嘱套餐和所述急诊病人的生命体征信息做出的医嘱。Set a preset disease doctor's order package, and record the doctor's order made by the doctor according to the preset disease doctor's order package and the vital sign information of the emergency patient.
可选的，所述急诊输液留观信息模块，还用于：Optionally, the emergency infusion observation information module is also used for:
更新输液留观的床位情况；Update the bed situation of infusion observation;
以及提取每个急诊病人在所述输液留观区产生的各项费用，输出第二结算结果。And extract various expenses generated by each emergency patient in the infusion observation area, and output the second settlement result.
可选的，所述急诊交班模块，还用于统计所述抢救区、所述输液留观区和各个急诊专科前一日的就诊人数和具有预设身份病人的就诊人数，以及每个急诊病人的费用缴纳情况和当日血库储备情况。Optionally, the emergency shift module is also used to count the number of visits of the rescue area, the infusion observation area and each emergency department the day before and the number of visits of patients with preset identities, and the number of visits of each emergency patient The payment of fees and the blood bank reserves on the day.
本发明的有益效果为：本发明提供的系统至少包括：急诊预检分诊信息模块、急诊抢救信息模块、急诊输液留观信息模块、急诊发热门诊信息模块、急诊交班信息模块，以急诊病人的完整救治过程为主线，全流程、全方位地追踪和监控医疗护理过程，特别是通过对救治过程中各个环节所经历时间的记录，以及对急诊医嘱处理全过程的跟踪，为临床科研积累宝贵的数据，因此，能够极大地节省医护人员书写标准化临床文书的时间，优化急诊医疗资源的配置，提高医护工作质量和急诊流程的效率。The beneficial effects of the present invention are: the system provided by the present invention at least includes: emergency pre-examination and triage information module, emergency rescue information module, emergency infusion observation information module, emergency fever clinic information module, emergency handover information module, with emergency patients The complete treatment process is the main line, and the whole process and all-round tracking and monitoring of the medical care process, especially through the recording of the time elapsed in each link of the treatment process and the tracking of the entire process of emergency doctor's order processing, has accumulated valuable information for clinical research. Data, therefore, can greatly save the time of medical staff writing standardized clinical documents, optimize the allocation of emergency medical resources, improve the quality of medical work and the efficiency of emergency procedures.
附图说明Description of drawings
图1为本发明实施例中急诊医疗信息系统的结构示意图；Fig. 1 is the structural representation of emergency medical information system in the embodiment of the present invention;
图2为本发明实施例中急诊抢救信息模块的结构示意图；Fig. 2 is the structural representation of emergency rescue information module in the embodiment of the present invention;
图3为本发明实施例中急诊患者就诊流程示意图。Fig. 3 is a schematic diagram of the medical treatment process for emergency patients in the embodiment of the present invention.
具体实施方式detailed description
下面将结合本发明实施例中的附图，对本发明实施例中的技术方案进行清楚、完整地描述，显然，所描述的实施例仅仅是本发明一部分实施例，并不是全部的实施例。基于本发明中的实施例，本领域普通技术人员在没有做出创造性劳动前提下所获得的所有其他实施例，都属于本发明保护的范围。The following will clearly and completely describe the technical solutions in the embodiments of the present invention in conjunction with the accompanying drawings in the embodiments of the present invention. Obviously, the described embodiments are only some of the embodiments of the present invention, not all of them. Based on the embodiments of the present invention, all other embodiments obtained by persons of ordinary skill in the art without making creative efforts belong to the protection scope of the present invention.
下面结合附图对本发明优选的实施方式进行详细说明。Preferred embodiments of the present invention will be described in detail below in conjunction with the accompanying drawings.
参阅图1所示，本发明实施例提供一种急诊医疗信息系统，该系统至少包括：急诊预检分诊信息模块110、急诊抢救信息模块120、急诊输液留观信息模块130、急诊发热门诊信息模块140、急诊交班信息模块150；其中，Referring to Fig. 1, an embodiment of the present invention provides an emergency medical information system, which at least includes: an emergency pre-examination and triage information module 110, an emergency rescue information module 120, an emergency infusion observation information module 130, and an emergency fever clinic information module. Module 140, emergency shift information module 150; wherein,
急诊预检分诊信息模块110，用于记录每个急诊病人的身份信息，并提取每个急症病人的生命体征信息，以及记录分诊护士根据每个急诊病人的生命体征信息为该急诊病人分配的就诊医生和病区。The emergency pre-examination and triage information module 110 is used to record the identity information of each emergency patient, extract the vital sign information of each emergency patient, and record that the triage nurse assigns the emergency patient according to the vital sign information of each emergency patient. visiting doctors and wards.
具体的，在记录分诊护士根据第i个急诊病人的生命体征信息为第i个急诊病人安排就诊医生和病区时，急诊预检分诊信息模块110记录分诊护士根据第i个急诊病人的生命体征信息参照预设的病情评分标准对急诊病人的病情的评分，并记录分诊护士根据评分结果为急诊病人安排的就诊医生和病区。Specifically, when recording that the triage nurse arranges a doctor and ward for the i-th emergency patient according to the vital sign information of the i-th emergency patient, the emergency pre-examination triage information module 110 records the triage nurse's According to the preset condition scoring standard, the emergency patient's condition is scored according to the vital sign information of the system, and the doctor and ward arranged by the triage nurse for the emergency patient are recorded according to the score result.
例如，将急诊病人总体分为“三区四级”，并结合急诊病人的来院方式和病人病情的相应评分标准对急诊病人进行预检分诊。For example, the emergency patients are generally divided into "three districts and four levels", and the emergency patients are pre-examined and triaged based on the way the emergency patients come to the hospital and the corresponding scoring standards of the patient's condition.
此外，急诊预检分诊信息模块110，还用于为针对患有预设疾病急诊病人预置对应的预设就诊医生和对应的预设病区。In addition, the emergency pre-examination and triage information module 110 is also used to pre-set corresponding preset doctors and corresponding preset wards for emergency patients suffering from preset diseases.
例如，可直接为严重创伤、心血管事件、脑出血及孕产妇的急诊病人开启绿色通道，直接分配至预先分配好的就诊医生和病区。For example, green channels can be opened directly for emergency patients of severe trauma, cardiovascular events, cerebral hemorrhage and pregnant women, and they can be directly assigned to pre-assigned doctors and wards.
此外，急诊预检分诊信息模块110还能实现对批量伤员来诊的分诊功能，即针对大量具有相似情况的病人集中进行分诊处理的能力，这样就大大减少了这些患者的就诊时间。In addition, the emergency pre-examination and triage information module 110 can also realize the triage function for batches of wounded patients, that is, the ability to centrally triage a large number of patients with similar conditions, thus greatly reducing the treatment time of these patients.
进一步地，急诊预检分诊信息模块110，还用于：Further, the emergency pre-examination and triage information module 110 is also used for:
记录每个分诊护士的工作量，以及根据各个就诊医生和各个病区负责人的反馈对每个分诊护士的工作准确性作出的评价。The workload of each triage nurse was recorded, and the evaluation of each triage nurse's work accuracy was made based on the feedback from each visiting doctor and each ward head.
急诊预检分诊信息模块110对分诊护士的工作量及工作准确性作出一定程度的考量和评价，可以不断提高分诊护士的工作能力和工作积极性，实现了分诊工作标准化、科学化，保障重症患者在最短的时间内优先得到诊治，并用最少的资源提供最好的急诊服务，减少患者的等待时间，使急诊工作“忙而不乱，快而准”的有计划、有秩序的进行，合理、科学地分配急诊科医疗资源和医疗空间，改善患者的救治效果，通过可量化的客观指标提高分诊准确率，使患者在合适的时间去合适的区域获得恰当的诊疗，而且使分诊人员的工作能力和效率不断提高。The emergency pre-examination and triage information module 110 considers and evaluates the workload and work accuracy of the triage nurses to a certain extent, which can continuously improve the work ability and work enthusiasm of the triage nurses, and realize the standardization and scientificization of the triage work. Ensure that critically ill patients receive priority diagnosis and treatment in the shortest time, provide the best emergency services with the least resources, reduce the waiting time of patients, and make the emergency work "busy but not chaotic, fast and accurate" in a planned and orderly manner , rationally and scientifically allocate medical resources and medical space in the emergency department, improve the treatment effect of patients, improve the accuracy of triage through quantifiable objective indicators, so that patients can go to the right area at the right time to get the right diagnosis and treatment, and make the triage The working ability and efficiency of clinic staff have been continuously improved.
参阅图2所示，急诊抢救信息模块120，用于记录针对每个急诊病人在抢救区的诊疗信息，该模块至少包括以下四个单元：Referring to Fig. 2, the emergency rescue information module 120 is used to record the diagnosis and treatment information in the rescue area for each emergency patient, and this module includes at least the following four units:
申请提交单元201，用于提交每个急诊病人的医疗行为申请。The application submitting unit 201 is used for submitting the medical behavior application of each emergency patient.
具体的，申请提交单元201，至少可以用于提交以下三种申请：Specifically, the application submission unit 201 can at least be used to submit the following three applications:
第一种：提交每个急诊病人的会诊申请，以及记录每个急诊病人的当前会诊状态和会诊意见。The first method: Submit the consultation application for each emergency patient, and record the current consultation status and consultation opinions of each emergency patient.
第二种：提交每个急诊病人的检验和影像检查的申请，以及记录每个急诊病人当前申请的检验和影像检查结果和以往的检验和影像检查结果，以及与现有医院信息系统进行数据共享。The second type: Submit the application for examination and imaging examination of each emergency patient, and record the current examination and imaging examination results and previous examination and imaging examination results of each emergency patient, and share data with the existing hospital information system .
例如，与医院信息系统及影像学资料系统进行数据共享。For example, data sharing with hospital information system and imaging data system.
第三种：提交发热急诊病人的传染病病原检查项目的申请。The third type: Submit an application for the inspection items of infectious disease pathogens for emergency patients with fever.
急诊医嘱单元202，用于至少收集每个急诊病人的检查化验结果、预设生命体征信息和/或会诊意见，记录每个就诊医生根据收集到的信息做出的医嘱。The emergency doctor's order unit 202 is configured to at least collect the inspection and test results, preset vital sign information and/or consultation opinions of each emergency patient, and record the medical order made by each visiting doctor based on the collected information.
具体的，急诊医嘱单元202设置了预设疾病医嘱套餐，记录就诊医生根据预设疾病的医嘱套餐和急诊病人的生命体征信息做出的医嘱。Specifically, the emergency doctor's order unit 202 sets a preset disease doctor's order package, and records the doctor's order made by the doctor according to the preset disease doctor's order package and the emergency patient's vital sign information.
例如，将消化道出血、急性心肌梗死、急性胆石症等，以预设医嘱套餐的形式陈列出来，可以由医生自主选择并对所下医嘱简单修改，并且这些医嘱套餐中的医疗干预措施都是依据每个疾病对应的疾病指南信息做出的，并且可以不断更新和增减，尤其是在应对批量伤员时，这大大减少了医生在下达医嘱上所花费的时间，能够快速地对患者完成救治，挽救患者生命。For example, gastrointestinal bleeding, acute myocardial infarction, acute cholelithiasis, etc., are displayed in the form of preset doctor's order packages, which can be selected by doctors themselves and simply modified by doctors, and the medical interventions in these doctor's order packages are all It is made according to the disease guide information corresponding to each disease, and can be continuously updated and added or subtracted, especially when dealing with mass casualties, which greatly reduces the time spent by doctors on issuing medical orders and can quickly complete the treatment of patients , saving the lives of patients.
急诊医嘱单元202还可用于将已开医嘱的药物直接打印处方，省去重新输入药物的步骤。The emergency doctor's order unit 202 can also be used to directly print a prescription for the medicine prescribed by the doctor, saving the step of re-entering the medicine.
因此，急诊医嘱单元202采用闭环管理模式，通过多种设备、技术做到全程跟踪医嘱和避免医护错误。此外，急诊医嘱单元202操作界面将急诊病人的检查化验结果、预设生命体征信息、会诊意见等集成起来，使医生可快速地查询到上述信息，并依据这些信息下达医嘱，使下医嘱过程更加准确、快速。Therefore, the emergency doctor's order unit 202 adopts a closed-loop management mode, and uses a variety of equipment and technologies to track the doctor's order and avoid medical errors. In addition, the operation interface of the emergency medical order unit 202 integrates the examination and test results of emergency patients, preset vital sign information, consultation opinions, etc., so that doctors can quickly query the above information, and issue medical orders based on these information, making the process of making medical orders easier. Accurate and fast.
急诊电子病历单元203，用于根据预设的电子病历模板，结合每个急诊病人的医嘱和处方，生成对应每个急诊病人的电子病历。The emergency electronic medical record unit 203 is configured to generate an electronic medical record corresponding to each emergency patient according to a preset electronic medical record template and in combination with each emergency patient's doctor's order and prescription.
急诊电子病历单元203包含许多电子病历模板，例如常见急重症的首次病程病历、查房病历，以及诸多知情同意书与其他许多制式书面材料，可以根据病情症状建立相应的基础病历，对可重复部分能够自动生成，主要关注与急诊病情相关的信息，提高了病历质量和效率，确保病历书写的及时性、完整性、准确性和安全性。而且急诊电子病历单元203实现了与住院系统病历信息的对接，可查询患者以往的住院信息，对患者在急诊的处理有非常重要的指导和借鉴意义。The emergency electronic medical record unit 203 contains many electronic medical record templates, such as the first medical records of common acute and severe cases, medical records of ward rounds, and many informed consent forms and many other standard written materials. Corresponding basic medical records can be established according to the symptoms of the disease. It can be automatically generated, mainly focusing on information related to emergency conditions, improving the quality and efficiency of medical records, and ensuring the timeliness, completeness, accuracy and safety of medical record writing. Moreover, the emergency electronic medical record unit 203 realizes the docking with the medical record information of the hospitalization system, and can query the patient's past hospitalization information, which has very important guiding and reference significance for the treatment of patients in the emergency department.
危机告警单元204，用于监控每个急诊病人的检查化验结果，在确定任一急诊病人的检查化验结果不满足预设要求时，通知值班医生。The crisis alarm unit 204 is used to monitor the examination and test results of each emergency patient, and notify the doctor on duty when it is determined that the examination and test results of any emergency patient do not meet the preset requirements.
计价管理单元205，用于提取每个急诊病人在抢救间产生的各项费用，输出第一结算结果。The pricing management unit 205 is used to extract various expenses incurred by each emergency patient in the rescue room, and output the first settlement result.
除以上5个基本模块外，还可以包括：In addition to the above 5 basic modules, it can also include:
护理单元：采用闭环医嘱管理模式，利用护士移动终端、印有条码标签或RFID标签的输液袋等技术，对输液医嘱执行确认，用于对各种诊疗环节进行确认，确保病人接受护理操作时的准确性和安全性。该系统模块可实时记录患者的病情状况和进展变化，可清晰直观地记录和查询患者的基本生命体征，并对患者可能存在的护理方面的风险进行评估预测，使护理工作做到更加全面仔细安全。此外该系统还具有将床旁监护仪、快速检测结果自动传输的功能，避免了输入繁琐量大的数字信息的工作量及可能出现的张冠李戴的现象，节省了护士的时间，提高了护理工作的效率和安全性。Nursing unit: adopt the closed-loop doctor's order management mode, use technologies such as nurses' mobile terminals, infusion bags printed with barcode labels or RFID labels, etc. to confirm the execution of infusion doctor's orders, which are used to confirm various diagnosis and treatment links to ensure that patients receive nursing care. Accuracy and Security. The system module can record the patient's condition and progress in real time, record and query the patient's basic vital signs clearly and intuitively, and evaluate and predict the possible nursing risks of the patient, making the nursing work more comprehensive, careful and safe . In addition, the system also has the function of automatically transmitting bedside monitors and rapid detection results, which avoids the workload of inputting cumbersome and large digital information and the phenomenon of being confused, saves time for nurses, and improves the efficiency of nursing work. efficiency and safety.
出入科管理单元：记录危重病人的基本信息及基本病情诊断，完成患者的出入管理。Entry and exit management unit: record the basic information and basic condition diagnosis of critically ill patients, and complete the entry and exit management of patients.
急诊输液留观信息模块130，用于记录每个输液留观的急诊病人在输液留观区的诊疗信息。The emergency infusion observation information module 130 is used to record the diagnosis and treatment information of each emergency patient who is under observation for infusion in the infusion observation area.
此外，急诊输液留观信息模块130，还用于更新输液留观的床位情况，以及提取每个急诊病人在输液留观区产生的各项费用，输出第二结算结果。In addition, the emergency infusion observation information module 130 is also used to update the beds for infusion observation, extract various expenses incurred by each emergency patient in the infusion observation area, and output the second settlement result.
具体的，急诊输液留观信息模块130主要针对病情较重需密切观察病情进展和病情相对平稳需要临时输液的来诊患者记录相关的诊疗信息。急诊输液留观信息模块130可记录留观输液病人的基本信息及基本病情诊断，完成患者的出入管理，还具有可直观地浏览留观区床位情况以及所有留观患者的信息、病情及化验检查结果的功能，实时记录患者的病情状况和进展变化。此外，留观输液区的医疗护理工作依然采用闭环医嘱管理模式，利用护士移动终端、印有条码标签或RFID标签的输液袋等技术，进行输液医嘱执行确认，确保病人接受护理操作时的安全性。此外，急诊输液留观信息模块130可自动提取患者在输液留观区域产生的各项费用，进而一键结算，快速准确高效。Specifically, the emergency transfusion observation information module 130 mainly records relevant diagnosis and treatment information for patients who are seriously ill and need to be closely observed for progress of the condition, and whose condition is relatively stable and require temporary infusion. The emergency infusion observation information module 130 can record the basic information and basic condition diagnosis of the observation infusion patients, complete the patient's entry and exit management, and can intuitively browse the bed situation in the observation area and the information, conditions and laboratory tests of all the observation patients The result function records the patient's condition and progress in real time. In addition, the medical care work in the observation infusion area still adopts the closed-loop doctor’s order management mode, using technologies such as nurse mobile terminals and infusion bags printed with barcode labels or RFID tags to confirm the execution of infusion doctor’s orders to ensure the safety of patients receiving nursing operations . In addition, the emergency infusion observation information module 130 can automatically extract various expenses incurred by patients in the infusion observation area, and then make one-click settlement, which is fast, accurate and efficient.
急诊发热门诊信息模块140，用于记录各种传染病病原检查项目的检查结果，并对确诊的传染病进行上报。The emergency fever clinic information module 140 is used to record the inspection results of various infectious disease pathogen inspection items, and report the confirmed infectious diseases.
急诊发热门诊区为新开发的模块，用于急诊发热门诊临床工作中对急诊患者的医疗行为的处理。急诊抢救信息模块120中的申请提交单元201可为急诊发热门诊提供快速的传染病病原检查项目的申请，就诊医生根据患者病情描述，快速地做出检查检验申请，并对确诊的传染病快速进入上报流程，做到快速甄别和反应，这对传染病的救治和控制有着重要的意义。The emergency fever clinic area is a newly developed module, which is used to deal with the medical behavior of emergency patients in the clinical work of the emergency fever clinic. The application submission unit 201 in the emergency rescue information module 120 can provide a rapid application for infectious disease pathogen inspection items for the emergency fever clinic. The doctor who sees the doctor can quickly make an application for inspection and testing according to the patient's condition description, and quickly enters the list of confirmed infectious diseases. The reporting process to achieve rapid identification and response is of great significance to the treatment and control of infectious diseases.
急诊交班信息模块150，用于收集每个急诊病人在抢救区和输液留观区的诊疗信息。The emergency shift information module 150 is used to collect the diagnosis and treatment information of each emergency patient in the rescue area and the infusion observation area.
此外，急诊交班信息模块150，还用于统计抢救区、输液留观区和各个急诊专科前一日的就诊人数和具有预设身份病人的就诊人数，以及每个急诊病人的费用缴纳情况和当日血库储备情况。In addition, the emergency shift information module 150 is also used to count the number of visits to the rescue area, the infusion observation area, and each emergency department on the previous day and the number of visits to patients with preset identities, as well as the payment status of each emergency patient and the number of visits on the day. Blood bank reserves.
急诊交班信息模块150，可以直接提取患者之前的检查检验结果信息、会诊记录以及一些其他的诊疗信息，并集成地直观地展示出来，从而减少了值班医生的工作量，同时可统计每个就诊区域及各个急诊专科前一日的就诊人数和具有预设身份病人的就诊人数的情况，例如接诊军人的情况，对日常急诊工作有指导作用。另外，该系统还可向我们提示所有的费用缴纳情况和当日我院血库的储备情况，这对急诊科的日常接诊工作有着非常重要的作用。The emergency shift information module 150 can directly extract the patient's previous inspection and test result information, consultation records, and some other diagnosis and treatment information, and display them in an integrated and intuitive way, thereby reducing the workload of the doctor on duty, and at the same time, statistics can be made for each visiting area And the number of visits to each emergency department on the previous day and the number of visits to patients with preset identities, such as the situation of receiving military personnel, have a guiding effect on daily emergency work. In addition, the system can also remind us of all the payment of fees and the blood reserve of our hospital on that day, which plays a very important role in the daily reception work of the emergency department.
下面以一个具体实施例说明本发明提供的系统(参阅图2和图3所示)。The system provided by the present invention will be described below with a specific embodiment (see Fig. 2 and Fig. 3).
张某因心前区不适急诊来诊，分诊护士赵护士应用急诊预检分诊信息模块记录张某的身份信息，性别男，年龄65，公费医疗，同时对张某的生命体征进行测量，并根据患者的症状为患者安排在急诊内科李医生处就诊。Zhang came to the emergency department due to precordial discomfort. The triage nurse Zhao used the emergency pre-examination and triage information module to record Zhang’s identity information, gender male, age 65, medical treatment at public expense, and measured Zhang’s vital signs at the same time. According to the patient's symptoms, he arranged for the patient to see a doctor in the emergency department of internal medicine Dr. Li.
在就诊过程中，患者张某出现心前区疼痛、大汗、呕吐等症状，李医生立即予以患者心电图等检查，心电图有心肌梗死的典型表现，李医生立即将患者张某送至抢救区(红区)，由刘医生接诊患者张某，刘医生应用急诊抢救信息模块，立即进行抢救、监护、完善检验检查，完成医嘱的下达、病历的书写等，明确患者诊断后，立即请心内科医生会诊，会诊医生对患者进行评估后决定立即拟为患者行冠脉支架治疗并收入心内科住院进一步治疗。在整个救治过程中护理系统保证了患者接受治疗的安全性和高效性。During the treatment process, the patient Zhang developed symptoms such as precordial pain, profuse sweating, and vomiting. Dr. Li immediately gave the patient an electrocardiogram and other examinations. The electrocardiogram showed typical manifestations of myocardial infarction. Dr. Li immediately sent the patient Zhang to the rescue area ( In the red zone), Dr. Liu received the patient Zhang. Using the emergency rescue information module, Dr. Liu immediately carried out rescue, monitoring, perfected inspections, completed the issuance of doctor's orders, writing of medical records, etc., and immediately consulted the cardiology department after confirming the patient's diagnosis The doctor consulted, and after evaluating the patient, the consulting doctor decided to immediately plan to perform coronary stent treatment on the patient and admitted him to the Department of Cardiology for further treatment. The nursing system ensures the safety and efficiency of patients receiving treatment throughout the treatment process.
因此，采用本系统可以对张某的整个医疗过程进行有效管理和监控，提供急诊工作质量和效率，很大程度上挽救的患者的生命。Therefore, the use of this system can effectively manage and monitor Zhang's entire medical process, improve the quality and efficiency of emergency work, and save the lives of patients to a large extent.
综上所述，本发明提供的系统以急诊病人的完整救治过程为主线，全流程、全方位地追踪和监控医疗护理过程，特别是通过对救治过程中各个环节所经历时间的记录，以及对急诊医嘱处理全过程的跟踪，为临床科研积累宝贵的数据，因此，能够极大地节省医护人员书写标准化临床文书的时间，优化急诊医疗资源的配置，提高医护工作质量和急诊流程的效率。In summary, the system provided by the present invention takes the complete treatment process of emergency patients as the main line, and tracks and monitors the medical care process in an all-round way, especially by recording the time elapsed in each link in the treatment process, and The tracking of the whole process of emergency doctor's order processing accumulates valuable data for clinical scientific research. Therefore, it can greatly save the time for medical staff to write standardized clinical documents, optimize the allocation of emergency medical resources, and improve the quality of medical work and the efficiency of emergency procedures.
本领域内的技术人员应明白，本发明的实施例可提供为方法、系统、或计算机程序产品。因此，本发明可采用完全硬件实施例、完全软件实施例、或结合软件和硬件方面的实施例的形式。而且，本发明可采用在一个或多个其中包含有计算机可用程序代码的计算机可用存储介质(包括但不限于磁盘存储器、CD-ROM、光学存储器等)上实施的计算机程序产品的形式。Those skilled in the art should understand that the embodiments of the present invention may be provided as methods, systems, or computer program products. Accordingly, the present invention can take the form of an entirely hardware embodiment, an entirely software embodiment, or an embodiment combining software and hardware aspects. Furthermore, the present invention may take the form of a computer program product embodied on one or more computer-usable storage media (including but not limited to disk storage, CD-ROM, optical storage, etc.) having computer-usable program code embodied therein.
本发明是参照根据本发明实施例的方法、设备(系统)、和计算机程序产品的流程图和/或方框图来描述的。应理解可由计算机程序指令实现流程图和/或方框图中的每一流程和/或方框、以及流程图和/或方框图中的流程和/或方框的结合。可提供这些计算机程序指令到通用计算机、专用计算机、嵌入式处理机或其他可编程数据处理设备的处理器以产生一个机器，使得通过计算机或其他可编程数据处理设备的处理器执行的指令产生用于实现在流程图一个流程或多个流程和/或方框图一个方框或多个方框中指定的功能的装置。The present invention is described with reference to flowchart illustrations and/or block diagrams of methods, apparatus (systems), and computer program products according to embodiments of the invention. It should be understood that each procedure and/or block in the flowchart and/or block diagram, and a combination of procedures and/or blocks in the flowchart and/or block diagram can be realized by computer program instructions. These computer program instructions may be provided to a general purpose computer, special purpose computer, embedded processor, or processor of other programmable data processing equipment to produce a machine such that the instructions executed by the processor of the computer or other programmable data processing equipment produce a An apparatus for realizing the functions specified in one or more procedures of the flowchart and/or one or more blocks of the block diagram.
这些计算机程序指令也可存储在能引导计算机或其他可编程数据处理设备以特定方式工作的计算机可读存储器中，使得存储在该计算机可读存储器中的指令产生包括指令装置的制造品，该指令装置实现在流程图一个流程或多个流程和/或方框图一个方框或多个方框中指定的功能。These computer program instructions may also be stored in a computer-readable memory capable of directing a computer or other programmable data processing apparatus to operate in a specific manner, such that the instructions stored in the computer-readable memory produce an article of manufacture comprising instruction means, the instructions The device realizes the function specified in one or more procedures of the flowchart and/or one or more blocks of the block diagram.
这些计算机程序指令也可装载到计算机或其他可编程数据处理设备上，使得在计算机或其他可编程设备上执行一系列操作步骤以产生计算机实现的处理，从而在计算机或其他可编程设备上执行的指令提供用于实现在流程图一个流程或多个流程和/或方框图一个方框或多个方框中指定的功能的步骤。These computer program instructions can also be loaded onto a computer or other programmable data processing device, causing a series of operational steps to be performed on the computer or other programmable device to produce a computer-implemented process, thereby The instructions provide steps for implementing the functions specified in the flow chart or blocks of the flowchart and/or the block or blocks of the block diagrams.
尽管已描述了本发明的优选实施例，但本领域内的技术人员一旦得知了基本创造性概念，则可对这些实施例作出另外的变更和修改。所以，所附权利要求意欲解释为包括优选实施例以及落入本发明范围的所有变更和修改。While preferred embodiments of the invention have been described, additional changes and modifications to these embodiments can be made by those skilled in the art once the basic inventive concept is appreciated. Therefore, it is intended that the appended claims be construed to cover the preferred embodiment as well as all changes and modifications which fall within the scope of the invention.
显然，本领域的技术人员可以对本发明实施例进行各种改动和变型而不脱离本发明实施例的精神和范围。这样，倘若本发明实施例的这些修改和变型属于本发明权利要求及其等同技术的范围之内，则本发明也意图包含这些改动和变型在内。Apparently, those skilled in the art can make various changes and modifications to the embodiments of the present invention without departing from the spirit and scope of the embodiments of the present invention. Thus, if the modifications and variations of the embodiments of the present invention fall within the scope of the claims of the present invention and equivalent technologies, the present invention also intends to include these modifications and variations.
Claims (9)
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| CN111081363B (en) * | 2019-12-23 | 2023-03-28 | 望海康信(北京)科技股份公司 | Emergency call observation management system and method |
| CN111724886A (en) * | 2020-05-11 | 2020-09-29 | 深圳市罗湖区人民医院 | Ambulance transport patient treatment management method based on critical value |
| CN111599452A (en) * | 2020-05-18 | 2020-08-28 | 河北东旭科技有限公司 | Emergency call information-keeping system |
| CN111599456A (en) * | 2020-06-17 | 2020-08-28 | 厦门大学附属心血管病医院 | A kind of infectious disease intelligent pre-check and triage machine and its pre-check method |
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| CN112635012A (en) * | 2020-12-21 | 2021-04-09 | 山东众阳健康科技集团有限公司 | Data processing method, system, medium and electronic equipment for emergency patients |
| CN112614589A (en) * | 2020-12-30 | 2021-04-06 | 四川互慧软件有限公司 | Central diagnosis and treatment method based on big data system |
| CN113270164A (en) * | 2021-04-19 | 2021-08-17 | 东莞市人民医院 | Medical advice cubing method for clinical test and clinical test medical advice system |
| CN113593689A (en) * | 2021-09-09 | 2021-11-02 | 资阳市第一人民医院 | Emergency treatment first aid management system |
| CN114613478A (en) * | 2022-03-02 | 2022-06-10 | 复旦大学附属中山医院 | Emergency Nursing Intelligent Management System |
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