Each laboratory uses a wide variety of laboratory LIS systems, each with its own advantages, and also has special functions formulated according to the undergraduate room's own system and environment. We will only discuss what most laboratories can do and strive to do at present. In general, the paperless process of LIS clinical laboratory automatic audit system can describe the development status of the system from three aspects.

1 臨床實(shí)驗(yàn)室自動(dòng)化

1 clinical laboratory automation

LIS系統(tǒng)是以檢驗(yàn)科的生產(chǎn)活動(dòng)為主要內(nèi)容，是檢驗(yàn)人員的機(jī)械臂與剪刀手。LIS實(shí)驗(yàn)室的發(fā)展離不開(kāi)實(shí)驗(yàn)室。近年來(lái)，隨著檢驗(yàn)醫(yī)學(xué)的發(fā)展和檢驗(yàn)標(biāo)本的快速增長(zhǎng)，實(shí)驗(yàn)室自動(dòng)化已成為檢驗(yàn)科的新趨勢(shì)/。實(shí)驗(yàn)室自動(dòng)化是指通過(guò)傳輸系統(tǒng)連接臨床實(shí)驗(yàn)室自動(dòng)化分析儀，實(shí)現(xiàn)樣品運(yùn)輸分類、預(yù)處理、檢測(cè)結(jié)果報(bào)告、后處理等全檢驗(yàn)過(guò)程的自動(dòng)化。

LIS system takes the production activities of the laboratory department as the main content, and is the manipulator and scissor hand of the inspectors. The development of LIS laboratory is inseparable from the laboratory. In recent years, with the development of laboratory medicine and the rapid growth of test specimens, laboratory automation has become a new trend in laboratory medicine. Laboratory automation refers to connecting the clinical laboratory automation analyzer through the transmission system to realize the automation of the whole test process such as sample transportation classification, pretreatment, test result report and post-processing.

2 自動(dòng)審核系統(tǒng)。

2. Automatic audit system.

檢驗(yàn)結(jié)果的準(zhǔn)確性和及時(shí)性是確保檢驗(yàn)質(zhì)量的核心內(nèi)容。等級(jí)醫(yī)院的評(píng)價(jià)標(biāo)準(zhǔn)也對(duì)檢驗(yàn)結(jié)果的審核提出了明確的要求，要求必須是高年級(jí)和雙重審核。從本研究結(jié)果中發(fā)現(xiàn)，由于生化標(biāo)本多，項(xiàng)目次數(shù)多，即使是高年級(jí)的結(jié)果審核，也不可避免地會(huì)出現(xiàn)錯(cuò)誤的檢查，給臨床診斷和治療帶來(lái)不必要的麻煩。實(shí)驗(yàn)室信息系統(tǒng)(LIS)介紹為解決這個(gè)問(wèn)題提供了解決方案。自我國(guó)大部分醫(yī)院檢驗(yàn)科介紹以來(lái)LIS自改進(jìn)以來(lái)，臨床生化結(jié)果的自動(dòng)審計(jì)規(guī)則不斷完善，臨床學(xué)生的檢測(cè)結(jié)果率顯著降低。研究結(jié)果發(fā)現(xiàn)，自動(dòng)審計(jì)與異常人工審計(jì)結(jié)果的檢出率之間的差異沒(méi)有顯著意義。結(jié)果表明，與人工審計(jì)相比，自動(dòng)審計(jì)在減少漏檢誤檢的前提下，大大節(jié)省了人工工作量，特別是在過(guò)濾掉大量非特殊檢查結(jié)果標(biāo)本（約占90%）時(shí)。

The accuracy and timeliness of inspection results is the core content to ensure the inspection quality. The evaluation standard of grade hospitals also puts forward clear requirements for the audit of test results, which must be senior grade and double audit. It is found from the results of this study that due to the large number of biochemical samples and the number of projects, even the result audit of senior grade will inevitably have wrong examination, which will bring unnecessary trouble to clinical diagnosis and treatment. The introduction of laboratory information system (LIS) provides a solution to this problem. Since the introduction of LIS in the laboratory departments of most hospitals in China, the automatic audit rules of clinical biochemical results have been continuously improved, and the test result rate of clinical students has been significantly reduced. The results show that there is no significant difference between the detection rate of automatic audit and abnormal manual audit. The results show that compared with manual audit, automatic audit greatly saves manual workload on the premise of reducing missed and false inspection, especially when filtering out a large number of non-special inspection results (about 90%).

自動(dòng)審計(jì)規(guī)則的建立是實(shí)現(xiàn)自動(dòng)審計(jì)的基礎(chǔ)，但前提是確保生化儀器的正常運(yùn)行，控制各生化檢驗(yàn)項(xiàng)目的質(zhì)量控制。在此基礎(chǔ)上，可根據(jù)臨床需要的實(shí)際工作經(jīng)驗(yàn)設(shè)置審計(jì)規(guī)則。例如，可以設(shè)置CK－MB≥CK規(guī)則一旦出現(xiàn)檢驗(yàn)結(jié)果CK-MB≥CK在情況下，儀器立即提醒審核員注意；設(shè)結(jié)果的界限，假設(shè)血清 Ｋ＋≥6.5ｍmol/L對(duì)于危重值，一旦出現(xiàn)檢驗(yàn)結(jié)果，儀器將立即提示危重值，并在審核人員審核前給出報(bào)警，防止泄漏。如果檢驗(yàn)結(jié)果特別異常，可以在負(fù)值或異常高時(shí)設(shè)置檢驗(yàn)項(xiàng)目報(bào)警，并給出相應(yīng)的提示。自動(dòng)審計(jì)規(guī)則的制定者需要掌握儀器的工作原理，熟悉實(shí)驗(yàn)前的質(zhì)量控制過(guò)程，并有扎實(shí)的臨床醫(yī)學(xué)知識(shí)，使審計(jì)規(guī)則合理有效。

The establishment of automatic audit rules is the basis of automatic audit, but the premise is to ensure the normal operation of biochemical instruments and control the quality control of biochemical inspection items. On this basis, audit rules can be set according to the actual work experience of clinical needs. For example, the CK-MB ≥ CK rule can be set. Once the inspection result CK-MB ≥ CK occurs, the instrument will immediately remind the auditor to pay attention; Set the limit of the result and assume that serum K + ≥ 6.5mmol/l. For critical value, once the test result appears, the instrument will prompt the critical value immediately and give an alarm before the audit by the auditor to prevent leakage. If the inspection result is particularly abnormal, you can set the inspection item alarm when the value is negative or abnormally high, and give corresponding prompts. The makers of automatic audit rules need to master the working principle of the instrument, be familiar with the quality control process before the experiment, and have solid clinical medical knowledge to make the audit rules reasonable and effective.

3 無(wú)紙化進(jìn)程

3 paperless process

醫(yī)院的無(wú)紙化過(guò)程是電子處理所有與診斷和治療相關(guān)的內(nèi)容?；颊咧怀钟幸粡?jiān)\療卡，就可以開(kāi)展一系列的診療活動(dòng)，如登記、驗(yàn)血功能檢查結(jié)果查詢和打印。對(duì)于醫(yī)學(xué)實(shí)驗(yàn)室，無(wú)紙化是指通過(guò)信息系統(tǒng)實(shí)現(xiàn)實(shí)驗(yàn)室管理過(guò)程的數(shù)字化，并將整個(gè)實(shí)驗(yàn)室的生態(tài)系統(tǒng)集成到實(shí)驗(yàn)室中LIS該系統(tǒng)包括但不限于打印排隊(duì)抽血報(bào)告等基本功能。

The paperless process of the hospital is to electronically process all the contents related to diagnosis and treatment. With only one diagnosis and treatment card, patients can carry out a series of diagnosis and treatment activities, such as registration, query and printing of blood test function test results. For the medical laboratory, paperless refers to the digitization of the laboratory management process through the information system, and the integration of the whole laboratory ecosystem into the laboratory LIS. The system includes but is not limited to the basic functions such as printing the queue blood drawing report.