Surgical anesthesia management system is a link that cannot be ignored in clinical anesthesia work. The anesthesiologist must make timely, true and accurate records of the patient's condition and signs changes during the anesthesia operation, the treatment measures taken, and postoperative follow-up. . Anesthesia records not only help to ensure the accuracy of clinical anesthesia, sum up experience and lessons, and improve the level of anesthesia technology, but also provide extremely valuable first-hand materials for clinical anesthesia teaching and scientific research. In addition, once a medical dispute case occurs, it is also an important legal basis. Therefore, the quality of anesthesia records is one of the key points of clinical anesthesia quality evaluation.
1. In the past, the anesthesia recording method was through paper forms. Anesthesiologists manually filled in a large number of patient operation information and vital sign data, and real-time recording was required. Not only was the workload heavy and inefficient, but it was also prone to errors, and the later archiving query was also extremely inconvenient. For the quality control of anesthesia orders, the statistics of anesthesiologists' work scenes, and the analysis of medication teaching data, it is also difficult to carry out work. Therefore, a surgical anesthesia management system was developed to replace the previous paper-based recording mode.
2. The electronic anesthesia record sheet mainly serves anesthesiologists, which reduces the pressure on anesthesiologists to record the anesthesia process and write medical documents, so that anesthesiologists can easily understand and inquire about patient-related information before surgery, and tailor-made for patients is more scientific. anesthesia regimen. Since most of the sign data are collected automatically and continuously to form a chart, the anesthesiologist can concentrate on the patient's anesthesia operation itself during the operation. When patients encounter emergencies during surgery, they can deal with emergencies more calmly and return to medical care itself.
3. The automatic collection of patients’ vital signs data by the surgical anesthesia management system can not only record the changes in the condition at that time more objectively, avoid the anesthesiologist’s busy recording and forget some important information, but also save time, so that the anesthesiologist can be more accurate. Fully analyze and judge the condition, and avoid mistakes when the doctor writes the record after the matter is processed. Significantly reduce the labor intensity of anesthesiologists, improve work efficiency, and improve the accuracy and objectivity of anesthesia management.
4. The surgical anesthesia management system can also help anesthesiologists make a more scientific evaluation of anesthesia after surgery, which is conducive to summarizing anesthesia experience. In addition, it also serves clinical nurses. The anesthesia information system realizes the information management of operations such as receipt of operation applications, operation anesthesia arrangements, operation anesthesia pricing, operation anesthesia statistics, anesthesia report summary, etc. Freed from manual statistics.
5. The digitization of the anesthesia record sheet also supports the statistical query of various clinical information, such as surgery query, medication statistics, anesthesia method statistics, etc. At the same time, it can also generate various documents and reports, such as surgical case teaching statistics, workload statistics, anesthesia quality statistics, etc., which greatly facilitates department management.
6. Surgery and anesthesia are a very important part of the hospital. Whether the surgeon performs an operation for the patient will directly endanger the life of the patient, so every link in the process of anesthesia for the patient is very important. With the development of high technology, a large number of auxiliary medical monitoring instruments and equipment are also widely used in the operation process, so that doctors can obtain the patient's vital parameters in time and make accurate and timely judgments. The operating room anesthesia information management system integrates various equipment in the operating room with the medical record data, inspection data, and image data of other information systems in the hospital to provide assistance for surgical anesthesia personnel, so that surgical anesthesia personnel can monitor timely and closely And make the most correct and timely disposal.
7. Introduction to the scheme of surgical anesthesia management system
The Operational Anesthesia Management System (DORIS) is a computer software system used in hospital operating rooms and anesthesia departments. The system tracks and manages patient information throughout the perioperative period, automatically integrates patient HIS, LIS, RIS, and PACS information, collects monitoring equipment data, and automatically generates electronic documents according to quality control requirements, saving anesthesiologists from the burdensome It is liberated from the document record, so that there is more time to escort the smooth progress of the operation. The anesthesia information management system covers the whole process from patient admission, preoperative, intraoperative, postoperative, to discharge. Through the information integration with the hospital information system and the data integration with the monitoring equipment, the automatic collection and sharing of perioperative patient information is realized, and the perioperative electronic medical record is established.
The surgical anesthesia management system follows the "patient-centered" design concept, freeing medical staff from the tedious writing of medical records, focusing on the diagnosis and treatment of patients, and spending more time on analysis and diagnosis. With the core of serving perioperative clinical business, it provides "standardized, normalized and streamlined" intelligent operating room for medical staff, business managers, and hospital leaders.
Eight, the advantages of surgical anesthesia management system
The operation and anesthesia information system includes the work content of three departments: anesthesiology department, extracorporeal circulation department, and operating room. The system can directly notify the staff of the three departments to arrange the operation and record the operation process in detail. The system has the advantages of improving work efficiency, clear text and graphics, and accurate real-time records.
1. It has a comprehensive and perfect query system, which can perform multi-condition and multi-key element query according to the user's multiple business models. The query conditions involve multiple data models, such as basic patient information, preoperative examination, intraoperative monitoring, postoperative evaluation, etc. . The system also provides a variety of data retrieval modes according to the clinical needs of surgical anesthesia and patient management, and longitudinally analyzes and filters dynamic data at different times according to different time points. And the queried data can generate different reports according to the needs, and provide printing function.
2. The patient overview module provides on-duty staff, directors, and head nurses to quickly understand the usage of the operating room and the current vital signs of patients in each operation.
3. The anesthesiology department of the operating room can independently calculate the operation fee bill, and can also interface with HIS and other financial related information.
4. The information summary module includes system data docking data such as HIS, EMR, LIS, PACS, etc., and can query relevant examination data and medical record information of patients at any time.
5. The instrument inventory module includes the inventory of instruments in various states before, during, and after surgery, ensuring that the instruments will not be lost or left in the patient's body.
6. You can apply for expert consultation, imaging consultation, pathological consultation, etc., manage the consultation list, select a consultation expert, and issue a consultation report.
7. It is possible to carry out two-way video communication, distance education and training, etc.
Finally, the cost information of the patient's surgical anesthesia can be directly generated through the anesthesia record sheet, and can also be supplemented. And the occurrence of arrears, which is convenient for the hospital to carry out cost accounting.