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医院信息化建设,无疑是一件好事,由于电脑的使用,给医生带来了便捷,也因为初建时期的不完善,也给医生带来了许多困惑。因为,有不少单位引进的是国外的技术和软件,不符合中国的国情,不符合医院的院情,引进的是西方的疾病分类学,与我们自己的国情,院情大大不同,不正确处理,弊端凸显,给医疗,科研工作又带来难以克服的麻烦。 现在我院应用的现行系统中的疾病名称分类,就与临床实际相差甚远。不知道别的医院的情况是怎么样,我们医院的疾病命名,据说是国际接轨的,在医生使用起来很不方便,脱离实际,门诊医生做出的常见病的诊断无法在诊断栏里打出来;双侧器官的单侧病变,无法给出左右;一人有多种疾病在门诊无法显示;有好多病只能打上疑似诊断.......在住院部这些问题同样存在。这些问题解决不好,其他问题就无从谈起。在这种情况下,资料不真实,不完整,经验无法总结,科研无从下手,医学还如何进步! 我做为一个老医生呼吁有关方面尽快开发符合中国国情的软件,尽快建立自己的详尽的细致的疾病命名及分类学。
开发的软件要能够方便医生根据不同的病情做更加详细的诊断包括分期,分型等。不是让医生在现有的疾病分类学的框架内做诊断,而是按实际病情做出实事求是的诊断。因为疾病分类学是永远落后于实际的。 医学的进步除了对现有疾病的理论认知,治疗技术的进步外还包括对不断涌现的新的疾病的认识,诊疗上的进步。新的发展几乎都是在现有的框架之外的,这才是真正的发展,创新,填空白。 如果不能满足这方面的需求,那你就只有当绊脚石和桎酷的分!
The construction of hospital information to the doctor bring confusion
Classification of individuals: Medical Humanities
The hospital information construction, it is a good thing, because the computeruse, the doctor brought convenience, but also because of construction during the early is not perfect, but also to the doctor brought a lot of confusion. Because,there are a number of units is the introduction of foreign technology andsoftware, do not meet the China conditions, do not meet the hospital situation,the introduction of nosological western, with our own national conditions, Chinese Academy of Sciences greatly different, not properly dealt with, to highlight the drawbacks, medical, scientific research work and difficult to overcome. Now the name of current system used in our hospital in the classification of disease, andclinical practice is far from. Don't know what is the situation of our hospital, the hospital disease named, is said to be international, divorced from reality in the doctor is not convenient to use, common disease diagnosis, doctors make that cannot be played out on the diagnosis of bar; bilateral organ unilateral lesion,cannot give; a variety of disease cannot be display in the outpatient; there are a lot of disease can only play on the suspected diagnosis.... also exists in theDepartment of the hospital. These issues are not properly solved, other problemswill be impossible. In this case, information is not true, incomplete, unable tosummarize experience, scientific research can not start, medicine and also how toprogress! I as an old doctor called for as soon as possible, in line with the development of Chinese conditions of the software, to establish their own detaileddetailed disease nomenclature and taxonomy as soon as possible. Development of the software to facilitate a doctor diagnose more detailed including stagingaccording to different condition, typing. Not to let a doctor diagnose in the framework of the existing disease taxonomy, but according to actual condition to make the diagnosis of seek truth from facts. Because the disease is always lags behind reality. The progress of medicine in addition to the theoretical cognition on existing disease, treatment technology also includes the understanding of the continuous emergence of new diseases, diagnosis and treatment progress.Almost all the new development is in addition to the existing framework, this is the real development, innovation, fill in the blank. If you can not meet this demand,then you only when stumbling and fetters cool points!
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