颌面外科向导式门诊电子病历系统的设计与实现

目的：为提高领面外科门诊电子病历的撰写速度和病历质量，设计部署向导式门诊结构化电子病历系统。方法：系统采用客户端、中间逻辑层和数据库层三层架构。主要功能模块包括“病历基本元素定义模块、病历模板管理模块、病历向导设计模块、系统综合查询与统计模块”。结果：开发完成的颌外门诊电了病历系统包括7大类，28个向导模块。支持某个症状与20颗乳牙（22个乳牙间隙）以及28颗恒牙（30个恒牙间隙）任意组合的描述。系统实施后，医生撰写病历地速度及病历本身的质量显著提高。结论：大型口腔专科医院的门诊量较大，颌面外科向导式门诊电子病历系统可以减轻医生撰与门诊病历的负担。该系统设计还可以推广到其它病种及治疗方法较规范的科室。

Design and Implementation of a Wizard-based Outpatient Electronic Medical Records for Oral and Maxillofacial Surgery

Objective： Design and implementation of a wizard-based outpatient electronic medical record system to improve the writing speed and quality of medical records for oral and maxillofacial surgery. Methods： The system uses three-tier architecture including ＂client, intermediate logical layer and database layer＂ . The main modules include basic elements definition module, template management module, the wizard design module, system integrated query and statistics module. Results： The deployed system includes 7 categories, 28 wizard modules. Any symptoms can be combined with 20 deciduous teeth （22 the deciduous teeth gap） and 28 permanent teeth （30 permanent teeth gap）. The writing speed and quality of outpatient medical records improve greatly. Conclusions： In stomatological hospitals with large number of outpatients, the wizard-based maxillofacial surgery outpatient electronic medical record system can reduce the burden of doctors for writing medical records. The system can also be extended to other similar departments.