According to system reform of the current medical insurance diagnosis related groups, quality control of rehabilitation medicine and requirements of information management, this paper constructs a rehabilitation information system by using the theoretical framework and core sets of International Classification of Functioning, Disability and Health (ICF). Then, the constructed system is embedded into the work of rehabilitation medicine team. By the four processes of ICF items evaluation, rehabilitation goal setting, team cooperation scheme formulation and reevaluation, the operation process of rehabilitation information management based on ICF is formed, which strengthens comprehensively the rehabilitation diagnosis and treatment standards and improves the efficiency of quality control management. The big data mining and multi-dimensional analysis in this platform can provide support of medical insurance payment, achieve exchanging and sharing rehabilitation medical quality control data among hospitals at different levels in different regions, assist tertiary referral and remote rehabilitation, improve the rehabilitation medical service system, and enhance the level of rehabilitation medical care. This paper will summarize the application experience of constructing ICF rehabilitation information management system.
目的 總結大型災害情況下,急診傷員信息收集流程,為制定大型災害救援提供證據支持。 方法 回顧性分析汶川地震(2008年5月12日-6月2日)和玉樹地震(2010年4月14日-5月1日)傷員信息收集方法,總結兩次地震傷員信息收集管理過程中發現的問題及取得的經驗。 結果 通過制作地震傷員登記表、調整病歷收集與管理模式、分診提前、傷員信息登記提前,調整急診功能分區、頭像采集技術的使用、成批傷員信息資料袋和分診信息卡的應用,最大限度地保證了傷員信息收集的完整性。 結論 地震傷員信息資料的準確性、完整性、及時性在傷員的救治、傷員的查找、傷員的轉歸和各類醫療信息的收集,以及制定大型災害事故應急預案等方面起著非常重要的作用。
A mobile operating room information management system with electronic medical record (EMR) is designed to improve work efficiency and to enhance the patient information sharing. In the operating room, this system acquires the information from various medical devices through the Client/Server (C/S) pattern, and automatically generates XML-based EMR. Outside the operating room, this system provides information access service by using the Browser/Server (B/S) pattern. Software test shows that this system can correctly collect medical information from equipment and clearly display the real-time waveform. By achieving surgery records with higher quality and sharing the information among mobile medical units, this system can effectively reduce doctors' workload and promote the information construction of the field hospital.