医院信息系统中化疗药物医嘱管理模块的开发与应用

发布时间：2018-01-20 01:23

本文关键词： 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　出处：《中国药房》2017年19期 　论文类型：期刊论文

【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 rationalization of prescriptions of chemotherapeutic drugs and to improve the safety of clinical use of chemotherapeutic drugs. To determine the factors and information that should be taken into account when designing the module of chemotherapeutic doctor's order management in hospital information system (HIS); Standardize and determine the standard chemotherapy plan, maintain the basic data, set the menu, expand the design of patient information based on HIS, drug and treatment program selection, warning and other functions. To realize the docking and effective application of chemotherapeutic medicine management module in HIS; The unreasonable rate of chemotherapeutic orders per month within 2 years after the operation of the statistical module was used to evaluate the application effect. Results and conclusion: the management module of chemotherapeutic orders developed in our hospital can realize the management of doctors' authorization. The patient's relevant information was automatically imported and the chemotherapy protocol was preset to facilitate the doctor's input and selection. After the module runs. Unreasonable chemotherapeutic orders decreased from 28 in the initial period (June 2014) to 4 in 2 years (June 2016). The procedure of prescribing chemotherapeutic orders was standardized. It has realized the information management, improved the efficiency and accuracy of the doctor's order input, provided the guarantee and support for standardizing the doctor's diagnosis and treatment behavior and evading the hospital risk, promoted the correct, safe and reasonable use of the chemotherapeutic drugs.
【作者单位】：新疆医科大学第一附属医院药学部;新疆医科大学第一附属医院信息中心;新疆医科大学第一附属医院肿瘤中心;
【基金】：新疆医科大学第一附属医院2014年度管理课题项目(No.2014SKQN11)
【分类号】：R95;TP311.52
【正文快照】： 恶性肿瘤是影响我国居民健康的主要慢性疾病之一,位居城镇居民死因第1位、农村居民死因第2位,化疗是恶性肿瘤的重要治疗方法[1]。目前,临床使用肿瘤化疗药物过程中仍存在一些不规范现象,不能切实体现化疗药物剂量和使用的个体化、规范化。随着我国医院乌鲁木齐830011)电子信息

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