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基于电子病历的台湾某医疗体系脑卒中登记系统的建立。

Establishment of electronic chart-based stroke registry system in a medical system in Taiwan.

机构信息

Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.

出版信息

J Formos Med Assoc. 2011 Aug;110(8):543-7. doi: 10.1016/S0929-6646(11)60081-8.

Abstract

To establish a prospective, real-time, self-sustainable stroke registry system, we incorporated a registry with an electronic chart to create an electronic chart-based stroke registry system in November 2006. The International Classification of Diseases Ninth Revision code (430-437) was used to auto-enroll stroke patients admitted to neurology departments. Clinical information was written by doctors, nursing information was recorded by nurses, and basic patient information was entered by administrative departments. Numerical data and the date and time of any studies were auto-downloaded from the hospital computer. In total, 212 items were auto-downloaded, including basic patient information, laboratory blood test and examination results, and the date and time of imaging and special intervention. The stroke scales (121 items, National Institutes of Health Stroke Scale, Barthel index, and modified Rankin scale) were designed to be auto-adjusted to reduce incompatibility. The 95 items with pull-down options were used to specify the contents. This registry system can be time-, labor- and money-saving with secured data accuracy.

摘要

为建立一个前瞻性、实时的、自我可持续的卒中登记系统,我们于 2006 年 11 月将登记处与电子病历相结合,创建了一个基于电子病历的卒中登记系统。采用国际疾病分类第九版代码(430-437)自动登记神经内科收治的卒中患者。临床信息由医生书写,护理信息由护士记录,基本患者信息由行政部门录入。数值数据和任何研究的日期和时间都从医院计算机自动下载。共自动下载了 212 项内容,包括基本患者信息、实验室血液检查和检查结果,以及影像学和特殊干预的日期和时间。卒中量表(NIH 卒中量表、巴氏指数和改良 Rankin 量表共 121 项)被设计为自动调整以减少不兼容性。使用带有下拉选项的 95 项来指定内容。这个登记系统可以节省时间、劳动力和金钱,并且数据准确性有保障。

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