“美耀醫(yī)院信息管理系統(tǒng)”是一套集門(mén)診掛號(hào)收費(fèi)、住院收費(fèi)、藥品管理等工作站的醫(yī)院網(wǎng)絡(luò)管理系統(tǒng)，該系統(tǒng)操作簡(jiǎn)單方便，性能穩(wěn)定；支持按大類(lèi)收費(fèi)和明細(xì)收費(fèi)；大類(lèi)項(xiàng)目和明細(xì)項(xiàng)目支持自定義；支持多種發(fā)票格式和收據(jù)格式，并且每種發(fā)票格式都可以自主修改；藥品管理部分參考了國(guó)外一些優(yōu)秀醫(yī)院網(wǎng)絡(luò)系統(tǒng)的先進(jìn)經(jīng)驗(yàn)，具有完善的藥品進(jìn)銷(xiāo)存管理功能，包括藥品調(diào)價(jià)報(bào)損退庫(kù)等。處方從門(mén)診收費(fèi)到藥房可完全通過(guò)網(wǎng)絡(luò)傳輸，完全實(shí)現(xiàn)無(wú)紙化，數(shù)據(jù)一次性發(fā)生，擺藥發(fā)藥全部自動(dòng)完成。本系統(tǒng)采用先進(jìn)的服務(wù)器客戶(hù)端結(jié)構(gòu)，客戶(hù)端運(yùn)行的只是和用戶(hù)交互的界面，安裝方便，對(duì)硬件的要求極低，能運(yùn)行 winXP 以上操作系統(tǒng)的計(jì)算機(jī)都能正常運(yùn)行。

目錄

系統(tǒng)登錄····························································································································· 6

一、 門(mén)診部分···················································································································· 7

（一） 門(mén)診醫(yī)生工作篇······························································································· 8

1.1 門(mén)診醫(yī)生站····································································································· 8

1.1.1 門(mén)診掛號(hào)······························································································· 8

1.1.2 門(mén)診病歷錄入······················································································ 10

1.1.3 開(kāi)具處方····························································································· 12

1.1.4 開(kāi)具檢驗(yàn)單·························································································· 13

1.1.5 開(kāi)具檢查單·························································································· 14

1.1.6 收治住院····························································································· 15

1.1.7 病歷模板維護(hù)······················································································ 16

1.1.8處方模板維護(hù)······················································································· 18

1.1.9 常用診斷設(shè)置維護(hù)··············································································· 18

1.1.10 常用檢查、檢驗(yàn)?zāi)０寰S護(hù)··································································· 19

（二） 門(mén)診護(hù)士工作篇····························································································· 20

2.1門(mén)診護(hù)士工作站····························································································· 20

2.1.1皮試····································································································· 20

2.1.2 執(zhí)行處方····························································································· 20

2.1.3 皮試結(jié)果查詢(xún)······················································································ 21

（三） 門(mén)診辦公室工作篇·························································································· 22

3.1排班管理········································································································ 22

3.1.1 午別維護(hù)····························································································· 22

3.1.2 排班模板管理（專(zhuān)家）········································································ 22

3.1.3 排班模板管理（專(zhuān)科）········································································ 22

3.1.4 專(zhuān)家排班····························································································· 23

3.1.5 專(zhuān)科排班····························································································· 24

3.2 門(mén)診管理······································································································· 24

3.2.1 醫(yī)生相關(guān)設(shè)置······················································································ 24

3.2.2 醫(yī)師級(jí)別相關(guān)設(shè)置··············································································· 25

3.2.3 診室設(shè)置····························································································· 26

二、 住院部分·················································································································· 27

（一） 住院醫(yī)生工作篇····························································································· 27

1.1 住院首頁(yè)······································································································· 27

1.1.1 住院申請(qǐng)單·························································································· 27

1.1.2 病案首頁(yè)····························································································· 28

1.1.3 診斷管理····························································································· 28

1.1.4 醫(yī)護(hù)變更····························································································· 29

1.1.5 費(fèi)用明細(xì)····························································································· 29

1.2 醫(yī)囑管理······································································································· 30

1.3 檢驗(yàn)申請(qǐng)······································································································· 32

1.4 檢查申請(qǐng)······································································································· 32

1.5 手術(shù)申請(qǐng)······································································································· 33

1.6 電子病歷······································································································· 34

1.7 三測(cè)單··········································································································· 34

1.8 會(huì)診管理······································································································· 35

1.8.1 會(huì)診申請(qǐng)····························································································· 35

1.8.2 查看本科申請(qǐng)會(huì)診申請(qǐng)單····································································· 35

1.8.3 查看本科接收的會(huì)診單的進(jìn)度······························································ 36

1.9 診斷及手術(shù)錄入····························································································· 36

1.10 出院············································································································ 37

1.10.1 出院帶藥錄入····················································································· 37

1.10.2 開(kāi)具出院醫(yī)囑····················································································· 38

1.11 數(shù)據(jù)模板維護(hù)······························································································ 38

1.11.1醫(yī)囑模板管理····················································································· 38

（二） 住院護(hù)士工作篇····························································································· 39

2.1 床位分配······································································································· 39

2.1處理單個(gè)病人醫(yī)囑·························································································· 40

2.1.1長(zhǎng)期醫(yī)囑（藥品）················································································ 40

2.1.2臨時(shí)醫(yī)囑（藥品）················································································ 40

2.1.3檢驗(yàn)檢查醫(yī)囑······················································································· 41

2.1.4手術(shù)醫(yī)囑······························································································ 42

2.2 批量處理醫(yī)囑································································································ 42

2.2.1長(zhǎng)期醫(yī)囑未審核···················································································· 42

2.2.2 長(zhǎng)期醫(yī)囑未停止··················································································· 43

2.2.3 長(zhǎng)期醫(yī)囑未執(zhí)行··················································································· 43

2.3 輸液卡、執(zhí)行單、口服藥卡、條碼打印·························································· 45

2.3.1 批量打印····························································································· 45

2.3.2 輸液卡································································································· 45

2.3.3 口服藥卡····························································································· 46

2.3.4 執(zhí)行單································································································· 46

2.3.5 打印單個(gè)病人······················································································ 47

2.4 醫(yī)囑執(zhí)行······································································································· 47

2.5 退費(fèi)·············································································································· 47

2.5.1 藥品退費(fèi)····························································································· 47

2.5.2 檢查退費(fèi)····························································································· 49

2.5.3 檢驗(yàn)退費(fèi)····························································································· 49

2.6 補(bǔ)費(fèi)·············································································································· 49

2.6.1 長(zhǎng)期需一直執(zhí)行的費(fèi)用········································································ 49

2.6.2 添加費(fèi)用····························································································· 50

2.7 護(hù)理文書(shū)······································································································· 50

2.7.1 護(hù)理記錄單·························································································· 50

2.7.2 三測(cè)單································································································· 51

2.7.3 交班記錄····························································································· 52

2.8 轉(zhuǎn)/出科········································································································· 52

2.8.1 轉(zhuǎn)科···································································································· 52

2.8.2 出科···································································································· 55

2.9 其他·············································································································· 57

2.9.1 催款單································································································· 57

2.9.2 患者擔(dān)保····························································································· 57

2.9.3 醫(yī)囑單打印·························································································· 58

（三） 手術(shù)工作站···································································································· 59

3.1 主業(yè)務(wù)操作···································································································· 59

3.1.1 手術(shù)排期····························································································· 59

3.1.2 手術(shù)信息、費(fèi)用錄入············································································ 59

3.1.3 退費(fèi)···································································································· 60

3.1.4 門(mén)診患者補(bǔ)費(fèi)······················································································ 60

3.1.5 模板維護(hù)····························································································· 61

三、 藥品物資管理部分···································································································· 62

（一） 庫(kù)房管理系統(tǒng)································································································· 63

1.1字典維護(hù)········································································································ 63

1.1.1 庫(kù)房管理····························································································· 63

1.1.2 藥房管理····························································································· 64

1.1.3 生產(chǎn)廠家維護(hù)······················································································ 64

1.1.4 供應(yīng)商維護(hù)·························································································· 65

1.1.5 藥品字典信息維護(hù)··············································································· 65

1.2 庫(kù)房主業(yè)務(wù)···································································································· 66

1.2.1 采購(gòu)計(jì)劃····························································································· 66

1.2.2 入庫(kù)管理····························································································· 67

1.2.3 藥品出庫(kù)····························································································· 68

1.2.4 藥品退庫(kù)····························································································· 69

1.2.5 退供應(yīng)商····························································································· 69

1.3 藥品管理······································································································· 70

1.3.1庫(kù)房庫(kù)存查詢(xún)······················································································· 70

1.3.2 藥品效期管理······················································································ 70

1.4.1 入庫(kù)統(tǒng)計(jì)····························································································· 72

1.4.2 出庫(kù)統(tǒng)計(jì)····························································································· 72

（二） 藥房管理系統(tǒng)································································································· 73

2.1 門(mén)診發(fā)藥······································································································· 73

2.1.1 留觀處方發(fā)藥······················································································ 74

2.1.2 一般處方發(fā)藥······················································································ 75

2.2 門(mén)診退藥······································································································· 75

2.3 病區(qū)業(yè)務(wù)······································································································· 76

2.3.1 病區(qū)擺藥····························································································· 77

2.3.2 病區(qū)退藥····························································································· 77

2.3.3 住院發(fā)藥匯總打單··············································································· 78

（三） 藥品會(huì)計(jì)管理系統(tǒng)·························································································· 79

3.1 盤(pán)點(diǎn)·············································································································· 79

3.2 庫(kù)位號(hào)管理···································································································· 79

3.3 藥品調(diào)價(jià)······································································································· 80

（四） 物資管理系統(tǒng)································································································· 81

4.1 物資基本信息維護(hù)························································································· 81

4.1.1 物資供應(yīng)商維護(hù)··················································································· 81

4.1.2 物資生產(chǎn)商維護(hù)··················································································· 81

4.2 出入庫(kù)管理···································································································· 83

4.2.1 入庫(kù)管理····························································································· 83

4.2.2 出庫(kù)管理····························································································· 83

4.2.3 庫(kù)存盤(pán)點(diǎn)····························································································· 84

（五） 設(shè)備管理系統(tǒng)································································································· 85

5.1 設(shè)備基本信息維護(hù)························································································· 85

5.1.1 設(shè)備供應(yīng)商維護(hù)··················································································· 85

5.1.2 設(shè)備生產(chǎn)商維護(hù)··················································································· 86

5.1.3 設(shè)備基礎(chǔ)資料維護(hù)··············································································· 86

5.2 設(shè)備庫(kù)存管理································································································ 87

5.2.1 入庫(kù)管理····························································································· 87

5.2.2 領(lǐng)用管理····························································································· 88

5.2.3 庫(kù)存盤(pán)點(diǎn)····························································································· 89

5.2.4 設(shè)備調(diào)撥····························································································· 89

5.3 設(shè)備事務(wù)管理································································································ 90

5.3.1 設(shè)備卡管理·························································································· 90

5.3.2 設(shè)備折舊····························································································· 90

5.3.3 設(shè)備報(bào)廢····························································································· 91

5.3.4 設(shè)備月結(jié)····························································································· 91

5.3.5 設(shè)備報(bào)修····························································································· 91

（六） 供應(yīng)室管理系統(tǒng)····························································································· 93

6.1 基礎(chǔ)資料維護(hù)································································································ 93

6.1.1 基礎(chǔ)包維護(hù)·························································································· 93

6.2 追溯管理······································································································· 93

6.2.1 清洗打包····························································································· 93

6.2.2 分發(fā)···································································································· 94

四、財(cái)務(wù)管理部分············································································································· 95

（一）結(jié)算中心系統(tǒng)··································································································· 95

1.1 門(mén)診主業(yè)務(wù)···································································································· 95

1.1.1 門(mén)診掛號(hào)····························································································· 95

1.1.2 退號(hào)···································································································· 97

1.1.3 門(mén)診結(jié)算····························································································· 98

1.1.4 門(mén)診退費(fèi)····························································································· 98

1.1.5 補(bǔ)費(fèi)···································································································· 99

1.1.6 門(mén)診開(kāi)單···························································································· 100

1.1.7 門(mén)診轉(zhuǎn)收···························································································· 100

1.2 門(mén)診結(jié)算管理······························································································ 101

1.2.1 門(mén)診結(jié)算信息····················································································· 101

1.2.2 門(mén)診結(jié)算日?qǐng)?bào)····················································································· 101

1.2.3 門(mén)診收入?yún)R總····················································································· 102

1.2.4 門(mén)診日結(jié)交賬····················································································· 102

1.3 住院主業(yè)務(wù)·································································································· 103

1.3.1 出院結(jié)算···························································································· 103

1.3.2 入院辦理···························································································· 104

1.3.3 取消住院···························································································· 105

1.3.4 預(yù)交··································································································· 105

1.3.5 退預(yù)交······························································································· 106

1.4 住院結(jié)算管理······························································································ 107

1.4.1 住院結(jié)算信息····················································································· 107

1.4.2 住院結(jié)算日?qǐng)?bào)····················································································· 107

1.4.3 住院預(yù)交報(bào)表····················································································· 108

1.4.4 住院日交結(jié)賬····················································································· 108

（二）票據(jù)管理中心································································································· 109

2.1 票據(jù)管理····································································································· 109

2.1.1 票據(jù)初始化管理················································································· 109

2.1.2 票據(jù)初始化查詢(xún)················································································· 109

2.1.3 票據(jù)初始化撤銷(xiāo)················································································· 110

2.1.4 票據(jù)領(lǐng)用管理····················································································· 110

2.1.5 票據(jù)領(lǐng)用查詢(xún)····················································································· 110

2.1.6 發(fā)票打印測(cè)試····················································································· 111

2.2 發(fā)票上傳····································································································· 111

五、病患管理查詢(xún)··········································································································· 113

（一） 病案管理系統(tǒng)······························································································· 113

1.1病案管理······································································································ 113

（二） 臨床路徑系統(tǒng)······························································································· 113

2.1臨床路徑維護(hù)······························································································· 113

2.1.1路徑維護(hù)···························································································· 113

（三） 病理管理系統(tǒng)······························································································· 114

（四） 康復(fù)管理系統(tǒng)······························································································· 114

4.1康復(fù)執(zhí)行······································································································ 114

六、其他部分·················································································································· 116

（一） 醫(yī)技工作站··································································································· 116

1.1 醫(yī)技類(lèi)型····································································································· 116

1.1.1 檢驗(yàn)··································································································· 116

1.1.2 檢查··································································································· 116

1.1.3 醫(yī)技補(bǔ)費(fèi)···························································································· 117

1.2 樣本管理····································································································· 117

（二） 一卡通管理··································································································· 117

2.1患者檔案新建······························································································· 117

2.2卡管理·········································································································· 118

2.3 賬戶(hù)管理····································································································· 119

（三） 醫(yī)保中心······································································································ 119

七、基礎(chǔ)數(shù)據(jù)維護(hù)··········································································································· 119

（一）系統(tǒng)管理中心································································································· 119

1.1 基本信息管理······························································································ 119

1.1.1 部門(mén)科室管理····················································································· 119

1.1.2 用戶(hù)組管理························································································ 120

1.1.3 系統(tǒng)用戶(hù)管理····················································································· 120

1.1.4 病案必填項(xiàng)配置················································································· 121

1.2字典維護(hù)······································································································ 121

1.2.1 診療項(xiàng)目維護(hù)····················································································· 121

1.2.2 組合項(xiàng)目維護(hù)····················································································· 122

1.2.3 醫(yī)師級(jí)別相關(guān)設(shè)置·············································································· 122

1.3病歷模板管理······························································································· 123

1.3.1 電子病歷模板····················································································· 123

1.3.2 門(mén)診病歷科室模板·············································································· 123

致謝································································································································ 124