CAJ | 학술논문

目的探讨规范记录口腔局部麻醉方案的环节控制模式。方法基于结构化门诊电子病历系统，以控制口腔局部麻醉方案的记录范式、内容片断模板和医师书写病历三个环节建立环节控制模式。结果基于病历记录环节控制模式，西安交通大学口腔医院相关门诊临床科室已经实现了规范记录口腔局部麻醉方案的目标。结论病历记录环节控制模式，不仅可以规范记录口腔局部麻醉方案、控制病历质量和服务于教学科研，而且具备应用通用性属性。
목적탐토규범기록구강국부마취방안적배절공제모식。방법기우결구화문진전자병력계통，이공제구강국부마취방안적기록범식、내용편단모판화의사서사병력삼개배절건립배절공제모식。결과기우병력기록배절공제모식，서안교통대학구강의원상관문진림상과실이경실현료규범기록구강국부마취방안적목표。결론병력기록배절공제모식，불부가이규범기록구강국부마취방안、공제병력질량화복무우교학과연，이차구비응용통용성속성。
Objective To explore the procedure control mode ( PCM ) for recording oral local anesthesia scheme .Methods Based on the structured outpatient electronic medical records system , PCM was established by controlling the recording paradigm of oral local anesthesia scheme , content fragments template and doctor's medical record writing .Results The goal of establishing recording oral local anesthesia scheme via PCM has been achieved in the related outpatient clinical departments of Stomatology Hospital of Xi'an Jiaotong University .Conclusion PCM can be applied not only in standardizing recording oral local anesthesia scheme but also in controlling medical records quality and serving teaching and research .In addition, PCM has the property of universal application .