浅谈实行电子病历后的思考

为加强我国医疗机构电子病历管理,规范电子病历临床使用,促进医疗机构信息化建设,卫生部制定了<电子病历基本规范(试行)>,并自2010年4月1日起施行,现就基层医院实际,结合病案管理,对实行电子病历后浅谈几点体会.     

融合多特征嵌入与注意力机制的中文电子病历命名实体识别

中文电子病历文本包含大量嵌套实体、句子语法结构复杂、句式偏短。为有效识别其医疗实体,提出一种融合多特征嵌入与注意力机制的命名实体识别算法,在输入表示层融合字符、单词、字形三个粒度的特征,并在双向长短期记忆网络的隐含层引入注意力机制,使算法在捕获特征时更加关注于医疗实体相关的字符,最终实现对中文电子病历中疾病、身体部位、症状、药物、操作五类实体的最优标注。面向开源和自建糖尿病数据集的实验结果中所提算法的实体识别准确率、召回率和F1值都达到97%以上,表明其可以更加有效地识别中文电子病历中各类实体。      

基于领域词典与CRF双层标注的中文电子病历实体识别

医疗实体识别是电子病历文本信息抽取的基本任务。针对中文电子病历文本复合实体较多、实体长度较长、句子成分缺失严重、实体边界不清的语言特点以及标注语料难以获取的现状,提出了一种基于领域词典和条件随机场（CRF）的双层标注模型。该模型通过对外部资源的统计分析构建医疗领域词典,再结合条件随机场,进行了两次不同粒度的标注,将领域词典识别的准确性和机器学习的自动性融为一体,从中文电子病历文本中识别出疾病、症状、药品、操作四类医疗实体。该模型在测试数据中的宏精确率为96.7%、宏召回率为97.7%、宏F1值为97.2%。同时对比分析了采用注意力机制的深度神经网络的识别效果,因受到领域数据集大小的限制,在该测试数据集中后者表现不佳。实验结果表明了该双层标注模型对中文医疗实体识别的高效性。      

临床药师如何应对临床路径管理

临床路径(clincal pathway.CP)是一种近年来才发展起来的诊疗标准化方法,对于缩短平均住院日、降低医疗费用、改善医息关系、提高医疗质量具有积极的意义.而临床药师作为临床路径实施过程中重要的组成部分,将面临新的机遇和挑战,将在多方面为医师和患者提供重要的、安全的药学服务.     

探讨呼吸机相关性肺炎临床诊治与分析

呼吸机相关性肺炎(VAP)是指原无肺部感染或原有肺部感染经呼吸机治疗后而发生的与呼吸机相关的感染,病原学常见为耐药菌与真菌等.在气管插管机械通气治疗后48 h或原有肺部感染用呼吸机48 h后发生新的感染,并经病原学证实.     

电子病历在医疗纠纷中的常见问题及对策

电子病历应用于医院管理,不仅提高了现代医院工作效率,但也带来了医疗纠纷的隐患。针对电子病历在医疗纠纷中的常见问题,提出通过提高法律意识、加强复制管理、完善系统设计、严格质控制度等措施,消除因电子病历的问题可能引起的医疗纠纷隐患,从而保证医疗安全和医疗质量。     

临床护理路径在慢性扁桃体手术中的应用

目的:探讨运用临床护理路径对慢性扁桃体手术患者实施整体护理的方法和效果.方法:将50例慢性扁桃体手术患者随机分为两组,两组均以整体护理为基础.对照组采用常规护理,实验组采用临床护理路径表,实施标准护理.结果:实验组平均住院天数低于对照组,健康知识掌握情况、患者满意度均高于对照组,具有统计学意义(P<0.05).结论:实施临床护理路径工作模式,提高了患者对疾病的认知度,缩短了住院天数,提高了患者的满意度.     

高校学科专业结构调整路径分析

学科专业结构调整具有较强的战略性,关键是适应社会发展的要求.学科专业结构调整的目的是满足社会需要,发挥引领和促进社会发展的作用.对学科专业结构调整进行深入思考,提出应对策略,如适应科学技术发展,实现学科交叉融合;以社会发展需求为导向,与产业结构调整相协调;合理规划学科布局,推动学科的非均衡可持续发展;政府宏观管理与高校自主调节相结合.     

电子铝箔剪切工序中的质量控制研究

本文主要研究电子铝箔在剪切工序中产生质量缺陷的种类、原因及改进措施。从刀垫选配、卷取轴选取、铝粉消除、管芯管理、刀具使用等几个方面进行系统分析,找出设备设计、使用、维护、管理上的不足,对造成电子铝箔质量缺陷的部分进行改善,以达到稳定并提升分切质量的目的。     

急诊昏迷患者的临床探讨

昏迷是临床常见病、多发病、疑难病、危重病的症状之一,病死率高.昏迷病人的救治往往涉及医学领域多专业、多学科知识,所以此类病人的临床急救不仅是急救医学的重点和难点,也是急诊科医师临床亟待攻克的课题.临床如何早期、正确地做出对病情的评估,并采取积极、有效的抢救措施,是防治神经系统功能障碍、降低神经系统后遗症、提高脑复苏及抢救昏迷患者成功的关键.     

A computerized obstetric medical record

Duke University has utilized computerized obstetric medical records since 1971. System evolution is described. Deficiencies in the current system appear to evolve from the computer/human interface rather than from basic system design. Critical elements in system success are physician acceptance of the appearance of data collection sheets and printed notes and continual rapid response in programing modification to allow for physician individuality and changes in medical practice. The limiting factor in the potential usefulness of such a system is the rate of incomplete data collection. It is suggested that if the physician were to enter data directly into the computer through a terminal, data collection would be more accurate and complete.     

Discrepancies between patient recall and the medical record. Potential impact on diagnosis and clinical assessment of chronic disease

BACKGROUND: During a case-control study, data necessary for fulfilling diagnostic and classification criteria for spondyloarthropathy were collected from 121 patients. OBJECTIVE: To study the potential impact of differences between patient recall and the medical record on diagnosis and clinical characterization of spondyloarthropathy as a model of chronic disease. METHODS: The study was conducted among four Alaskan Eskimo populations served by the Alaska Native Health Service. Two sets of historical data were compiled for each subject, one acquired during the interview and the other derived from the medical record. Paired items from the interview and the medical record were analyzed to determine discrepancies and consequent effects on diagnosis, classification, and disease characterization. RESULTS: Significant differences were observed in the reporting of genitourinary or diarrheal illnesses preceding or associated with arthritis, the occurrence of eye inflammation in association with joint pain, the occurrence of joint pain and back pain together, and the age at onset of back pain all of which are important to the diagnosis and classification of spondyloarthropathy. In contrast, for information needed to establish the probable inflammatory nature of back pain, patient interview was more helpful than the medical records, which did not provide adequate details to differentiate inflammatory from mechanical back pain. CONCLUSIONS: Patient recall bias can substantially affect diagnosis and clinical assessment of chronic disease, as exemplified by spondyloarthropathy. Reliance on records alone, however, may lead to underestimation of features that require subjective appraisal by the patient.     

The computer-based patient record challenges towards timeless and spaceless medical practice

Although computerization is increasingly advocated as a means for hospitals to enhance quality of care and control costs, few studies have evaluated its impact on the day-to-day organization of medical work. This study investigated a large Computerized Patient Record (CPR) project ($50 million U.S.) aimed at allowing physicians to work in a completely electronic record environment. The present multiple-case study analyzed the implementation of this project conducted in four hospitals. Our results show the intricate complexity of introducing the CPR in medical work. Profound obstructions to the achievement of a tighter synchronization between the care and information processes were the main problems. The presence of multiple information systems in one (Communication, Decision Support, and Archival record keeping) was overlooked. It introduced several misconceptions in the meaning and codification of clinical information that were then torn apart between information richness to sustain clinical decisions and concision to sustain care coordination.     

医院抗精神病药临床应用探讨

目的:对抗精神病药临床应用进行研究,从而加强临床合理用药的发展.方法:对某医院 2008-2010年三年的抗精神病药的应用进行分析.结果:该医院抗精神病药的种类及金额等呈逐年增加的趋势,并进一步阐述抗精神病用药的注意事项.结论:临床抗精神病药的应用合理性进一步加强,非典型抗精神病药的应用呈逐年上升趋势.     

人文关怀在临床护理中的探讨

加强人文关怀是临床护理工作的迫切需求,然而护理人员对人文关怀概念十分陌生.通过理解人文素质的内涵,我们探讨了培养护理人员人文素质的必要性及相应对策.护理人员只有将人文关怀体现到护理服务的全过程,才能为病人提供高品质的护理服务.     

Number of diagnoses in the final report and in the medical record

One hundred patient records of an internistic outpatient clinic were evaluated retrospectively for differences regarding the number of diagnoses in the documentation and the final report. Whereas the final or interim reports on the average contained 2.8 clinically relevant diagnoses, screening of the total documentation let the number rise to 3.5. Mainly the reports qualified as qualitatively poor led to overlooked or neglected relevant findings. Our results underline the importance of a meticulously kept medical record for a medical practice of high standards and responsibility.     

张元素医学思想及临证经验探析

宋金元时期是"新学肇兴"与中医理论深入探索的重要阶段[1].张元素是这个时代医学界不可不提的重要人物.他重视<内经>的运气学说,但不刻板,运用灵活,将运气学说与临床实际相结合[2].在临证时,他通过辨别脏腑寒热虚实来分析疾病的发生、发展及转归,主张化裁古方,创用新方.此说对后世医家临证诊疗多有启悟.     

44例采用血管内介入方式治疗颅内动脉瘤临床分析

血管内栓塞动脉瘤腔是一种微创、安全、有效治疗动脉瘤的方法.选择正确的技术和方法对改善动脉瘤栓塞治疗效果,减少并发症有重要意义.研究血管内介入治疗颅内动脉瘤的手术分析及相关影响因素,选择正确技术对改善治疗效果,减少并发症有重要意义.