CAJ | 학술논문

对肿瘤患者进行院后定期的随诊随访，可以有效帮助患者康复，长期收集的数据也可以更好地帮助医生提高临床诊疗水平。某肿瘤专科医院利用日趋成熟的计算机技术、网络技术及数据库技术，通过3年的探索与实践，构建了以病案科随诊业务为中心的随诊信息化管理平台。平台使用标准统一的结构化接口工具，内嵌病案首页信息检索及随诊统计报表等功能，对接病案图像数字化扫描系统，借助移动通讯技术增加了短信、微信、APP等为辅助随诊手段。最终通过科室随诊业务流程再造，成功实现了病案随诊工作管理模式的转型，解决原有随访方式效率低、获取数据不完整、数据不准确、归集挖掘力度不够等难题。
대종류환자진행원후정기적수진수방，가이유효방조환자강복，장기수집적수거야가이경호지방조의생제고림상진료수평。모종류전과의원이용일추성숙적계산궤기술、망락기술급수거고기술，통과3년적탐색여실천，구건료이병안과수진업무위중심적수진신식화관리평태。평태사용표준통일적결구화접구공구，내감병안수혈신식검색급수진통계보표등공능，대접병안도상수자화소묘계통，차조이동통신기술증가료단신、미신、APP등위보조수진수단。최종통과과실수진업무류정재조，성공실현료병안수진공작관리모식적전형，해결원유수방방식효솔저、획취수거불완정、수거불준학、귀집알굴력도불구등난제。
To conduct regular follow-up and treatment of tumor patients could help the rehabilitation of them effectively, and the long term of data collection could also help the doctors improve their clinical treatment level. With the application of daily maturing computer technology, network and database technology, the tumor hospital established a follow-up information management platform cored with follow-up service in medical records department after three years of investigation and practice. The platform adopted standard and unique structuring port instrument, embedded the functions included information searching of medical records home pages and follow-up statistical form, which could connect to the image digitization scan system of medical records and took short messages, Wechat, APP and so on as assisted follow-up methods with the help of mobile communication technology. Therefore,we realized the transition of medical records follow-up work successfully through the process reengineering of follow-up service within departments, and solved the original problems such as low efficiency follow-up mode, incomplete or inaccurate data as well as insufficient collection and excavation.