設計與實作出院病歷摘要系統

出院病歷摘要系統是病歷檔案中一項重要的臨床資料，精簡摘要病人住院期間的狀況。我們使用基於網路架構發展台大醫院新式出院病歷摘要系統，改善傳統主從架構的舊式系統。本論文詳細介紹設計考量與實作層面介紹，包含病摘查詢檢索、範本片語引用、病摘列表以及主要編輯區域等其他編輯功能。此外新系統加入多項新穎技術來提高系統使用性和互動性。最後比較新舊系統探討之間差異、使用新技術後之品質評估、檢視新系統的完整性，以及使用者實際測試情形並測量使用後的滿意度。

關鍵字

出院病歷摘要；醫療紀錄；醫療照護品質

並列摘要

Discharge summary is one of important clinical data in medical records, and it concisely summarizes the patient’s stay during hospitalization. In this thesis, we use web-based architecture in developing a new discharge summary system of National Taiwan University Hospital, and improve the traditional client/sever architecture of old system. This thesis introduces the design considerations and implementation level in detail, including summary search and query, model and phrase quoted, summary check list, major editing blocks and other functionalities. In addition, the new system incorporates several novel technologies to improve the usability and interactivity. Finally, we discuss a comparison between the client/sever and web-based system, assess the quality of new technology, survey the completeness of new system as well as the actual user test and user satisfaction.

並列關鍵字

discharge summary ； medical records ； quality of medical care

參考文獻

[1] Robert H. Miller and Ida Sim, “ Physicians’ Use of Electronic Medical Records: Barriers and Solutions”, Pursuit Of Quality 2004, March/April, 2004.

[2] R. Haux, A. Winter, E. Ammenwerth, B. Brigl,“ Strategic Information Management in Hospitals: An Introduction to Hospital Information Systems”, Springer, New York, 2004.

[4] S. H. Hsieh'2, S. L. Hsieh'4, Y. C. Weng, “Middleware based Inpatient Healthcare Information System”, IEEE 2007.

[6] InSook Cho and Hyeoun-Ae Park, “ Development and evaluation of a terminology-based electronic nursing record system”, Journal of Biomedical Informatics 36 (2003) 304–312, August, 2003.

[3] 范碧玉許清曉黃勝雄,“病歷書寫參考指引”, 中華民國醫療品質協會 2005

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國際替代計量

設計與實作出院病歷摘要系統

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