一個製作臨床病歷記錄的網基平台

A Web-based Platform for Implementing Clinical Notes

為推行電子病歷，台中榮總發展了一個製作臨床病歷記錄的網基平台。此平台將每一份臨床記錄分為樣式與內容兩部份，並提供樣式設計家、內容編輯器及記錄產生器等功能。各臨床單位可利用樣式設計家設計所需的臨床記錄樣式；醫師則以內容編輯器輸入病歷資料；記錄產生器可依樣式將輸入的內容資料轉換成文章式的臨床記錄供線上閱覽或列印。輸入的病歷資料以XML格式儲存於資料庫中，可提供日後臨床人員進行醫學研究分析。使用本網基平台發展臨床病歷記錄，不須軟體發展人員的介入，可節省大量的發展人力，亦大幅簡化並縮短了臨床病歷記錄電腦化的過程。目前已完成的臨床記錄樣式共有144種，包含全院各臨床科的住院病歷摘要、手術記錄、及出院病歷摘要。

Taichung Veterans General Hospital has developed a web-based platform for implementing clinical notes as a pilot system to promote electronic patient records. Each clinical note is partitioned into a template and a set of data contents. The platform provides three functions, named template designer, content editor, and note generator, for physicians to implement patients' clinical notes. The template designer is used to set up the format, called template, of a clinical note. A physician may enter and edit contents of a clinical note by the content editor under its template. According to the template and entered contents, the note generator generates a textual note for review and print. Using this web-based platform, a hospital may simplify the process in implementing her tremendous clinical notes without devoting any application designer. There are 144 templates of admission notes, operation notes, and discharge notes in TCVGH now.