[1]郭建军徐挺玉黄忠秋王兵索海燕章娣刘云.非药物医嘱闭环管理探讨[J].中国卫生质量管理,2021,28(01):039-41.[doi:10.13912/j.cnki.chqm.2021.28.1.11 ]
　GUO Jianjun,XU Tingyu,HUANG Zhongqiu.Discussion on Closed Loop Management of Non-Medicated Medical Advice[J].Chinese Health Quality Management,2021,28(01):039-41.[doi:10.13912/j.cnki.chqm.2021.28.1.11 ]
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非药物医嘱闭环管理探讨
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《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第28卷
期数:
2021年01期
页码:
039-41
栏目:
医疗质量
出版日期:
2021-01-28

文章信息/Info

Title:
Discussion on Closed Loop Management of Non-Medicated Medical Advice
作者:
郭建军徐挺玉黄忠秋王兵索海燕章娣刘云
南京医科大学第一附属医院
Author(s):
GUO Jianjun; XU Tingyu; HUANG Zhongqiu
The First Affiliated Hospital with Nanjing Medical University
关键词:
医嘱闭环; 互联互通; 医疗质量; 临床信息系统
Keywords:
Closed-Loop of Doctor's Advice; Connectivity; Medical Quality;  Clinical Information System
分类号:
R197.323
DOI:
10.13912/j.cnki.chqm.2021.28.1.11
文献标志码:
B
摘要:
通过建立由医嘱开立系统、临床数据平台、预约系统、各专科专项信息系统组成的医嘱闭环管理系统，实现信息交互共享，使检查、检验、输血、手术、治疗类等非药物医嘱各执行环节实时准确操作和记录，形成管理闭环。这避免了医疗差错发生，规范了诊疗流程，使医嘱执行全过程准确记录且可追溯，并对医嘱管理信息实时质控。下一步需加大信息化建设力度，对医嘱记录信息进行全方位监控和处理分析，从而进一步提高医疗质量。
Abstract:
Through the establishment of a closed loop management system of medical advice composed of doctor's order system, clinical data platform, appointment system, and special information systems of various specialties, information exchange and sharing can be realized, which achieves the real-time and accurate operation and record of all execution links of non-medicated medical advice, such as examination, laboratory test, blood transfusion, surgery, and treatment, and it can form a closed management loop. This avoids the occurrence of medical errors, standardizing the diagnosis and treatment process, making the entire process of the execution of medical orders accurately recorded and traced, and making the real-time quality control of the management information of medical orders. In the next step, it is necessary to strengthen the information construction, comprehensively monitor, process and analyze the medical advice record information, so as to further improve the medical quality.

参考文献/References:

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更新日期/Last Update: 2021-01-28