张董晓 贾楠 马红玉

    [摘要] 专病门诊就是近年来迅速发展的一种门诊服务模式，电子病历具有样本量大、更符合临床实际等诸多优点。模式化电子病历和专病门诊相结合可定向整理收集某一专病病例，对专病疗效提升、新药研发等多方面具有重要意义。本文以首都医科大学附属北京中医医院乳腺科浆细胞性乳腺炎专病门诊为例，探讨电子病历在专病门诊建设中的价值及应用。从专病门诊电子病历的模板设计及操作流程及应用效果两方面进行阐述，发现专病门诊中的电子病历可有效形成高质量专病临床数据集;提高对疾病认知水平，未病先防;形成临床决策;优化临床路径;为教学提高丰富素材，提高教学水平。电子病历的累积对专病门诊的建设起到重要的作用，是提升学科实力的重要途径。

    [关键词] 电子病历;专病门诊;学科建设

    [中图分类号] R197.323;R659? ? ? ? ? [文献标识码] A? ? ? ? ? [文章编号] 1673-7210(2020)02(c)-0174-04

    [Abstract] Disease-oriented outpatient clinic is a rapidly developing outpatient service mode in recent years. Electronic medical record has many advantages， such as large sample size， more in line with clinical practice and so on. The combination of the model electronic medical record and the disease-oriented outpatient clinic can be used to collect a specific disease case， which is of great significance to the improvement of the special disease efficacy and development of new drugs. This paper discusses the value and application of electronic medical record in the construction of disease-oriented outpatient clinic， taking the plasma cell mastitis of galactophore department of Beijing Traditional Chinese Medicine Hospital ......