Source code of the clinical information system for surgical anesthesia
The function of surgical anesthesia clinical information system meets the review requirements of tertiary A hospitals, and realizes comprehensive docking with existing information systems of hospitals such as HIS, LIS, PACS, EMR and other systems, fully covering the whole process from patient admission, preoperative, intraoperative, postoperative, to discharge. Through the equipment integration with related medical instruments, it is easy to integrate traditional monitoring equipment in the operating room such as monitors, anesthesia machines, ventilators, and can also be docked with blood gas analyzers and other equipment to quickly obtain intraoperative test results. At the same time, it is integrated with the information of the hospital information system to realize the automatic collection and sharing of perioperative patient information, and fully supports anesthesia document records, anesthesia process management, anesthesia intraoperative event management, anesthesia resuscitation management, etc.
System Features:
Doctor's experience and workload accumulation, automatic acquisition of basic patient information;
Drug material preparation and systematic self-accounting, obtaining medical records to establish the plan;
Medical record review intraoperative protocol data collection;
Collect patient information, comprehensively browse intraoperative information, and automatically generate various statistics;
Electronic medical record information exchange, bill return transmission, financial statistics;
Postoperative follow-up, disease course records, treatment plans, analgesic treatment, automatic generation of various statistics, analysis.
Functional modules:
1. Surgical nursing system
Surgical application: support the opening, cancellation, execution and other operations of the surgical application, support the printing of surgical orders, etc.;
Nursing records: surgical nursing work needs to be carried out during and after surgery, and surgical nursing records and surgical fee records are completed;
Surgical billing: supports operating room billing and backhaul of billing data to HIS.
2. Anesthesia management
Anesthesia visit: anesthesiologists need to record the process of surgical anesthesia, including changes in the patient's vital signs from the monitor, including preoperative, intraoperative, and postoperative anesthesia induction records, as well as intraoperative anesthesia records, various laboratory tests, postoperative anesthesia summary, and postoperative follow-up;
Preoperative: anesthesia visit, anesthesia plan, informed consent, risk assessment, safety check;
Intraoperative: sign monitoring, critical event recording, safety check resuscitation: sign monitoring, medication management;
Postoperative: postoperative follow-up, postoperative analgesia, anesthesia summary;
Informed consent: support informed consent;
Risk assessment: support surgical risk assessment;
Safety check: support pre-anesthesia safety check, support pre- and post-operative safety check;
Anesthesia detection: continuous measurement and observation of the patient's physiological functions and recording during anesthesia and surgery;
Postoperative analgesia: refers to analgesia interventions that include the entire perioperative period before, during, and after surgery;
Anesthesia resuscitation: provide resuscitation event recording function, time can be automatically generated, and the amount of entry and exit can be automatically calculated;
Anesthesia summary and postoperative visits: records to support anesthesia effects, records to support awakening, and records to support analgesic treatment.
3. Department management
Interoperative arrangement: the surgical nurse needs to schedule the operation before the operation, register the information that has been booked, arrange each scheduled operation, support the cancellation of scheduled surgery and the scheduled operation, and support the change of the patient's surgical information;
Anesthesia scheduling: Anesthesiologists need to be scheduled to prepare sterilization equipment kits and surgical consumables;
Nurse scheduling: Nurses are managed in shifts.