Shimada M, Akazawa K, Higashi H, Watanabe Y, Hayashi Y, Moriguchi S, Fujisawa K, Nose Y
Kyushu University Hospital, Fukuoka, Japan.
Jpn Hosp. 1990 Jul;9:49-54.
We developed a medical summary report system. In this system, each department can specify the predetermined conditions for issuing the summary report. The summary is made through a hierarchical database in the integrated hospital information system according to the predetermined conditions. The summary automatically issued after reception of the outpatient, or also issued by on-line summary report program with the patient number if requested by doctors. The report is sent to the proper consulting room from the reception desk using an air-shooter. The report contains the patient information such as a patient name, age, sex, birthday, a clinic name, a chart number, a patient number, diagnoses and examinations. The doctors can refer to the points of the clinical history of the patient in his own and other departments, and make a correct diagnoses and avoid the overlaps of the examinations and medications. This system has contributed to the quality-up of the patient care by availability of patient information even in other departments without the medical chart.
我们开发了一个医学总结报告系统。在这个系统中，每个科室都可以指定出具总结报告的预定条件。总结是通过综合医院信息系统中的分层数据库根据预定条件生成的。总结在门诊接待后自动出具，或者如果医生要求，也可通过在线总结报告程序使用患者编号出具。报告通过气动弹射器从接待台发送到相应的诊室。报告包含患者信息，如患者姓名、年龄、性别、生日、诊所名称、病历号、患者编号、诊断和检查结果。医生可以参考患者在其所在科室及其他科室的临床病史要点，做出正确诊断，避免检查和用药的重复。该系统通过在没有病历的其他科室也能获取患者信息，为提高患者护理质量做出了贡献。
