摘要
目前电子病历系统在医院中得到了广泛应用,但是病历归档却迟迟未能突破传统的纸质病案存储模式。始终被成本高、效率低、难以及时共享等问题所困扰。2013年我院为实现电子病历的无纸化存储,建立了电子病历文件管理与应用系统,使分散在各临床业务系统当中的信息以病人为中心汇总和组织起来。该系统具有终末病历的质控、归档、存储、共享等功能,实现了电子病历无纸化归档、阅览,从而减少纸质病历。本文详细介绍了该系统建立的意义、必备的条件、操作流程、注意事项等。通过4年的运行证明了该应用系统是安全、有效的病案管理新模式。
At present electronic medical record system has been widely used in hospitals,but the medical ecords filling has not been able to break through the traditional paper-based medical record storage mode. It was always plagued by high cost,low efficiency,difficult to share in time and so on. In 2013,in order to develope paperless storage of electronic medical records,our hospital established the electronic medical records management and application system,so that the information scattered among the various clinical business systems could be organized and organized by patients as the center. The system has the functions of quality control,filing,storage and sharing of the final medical records,and developing the paperless filing and reading of electronic medical records,thus reducing the paper medical records. This paper introduced the significance of establishing the system,the necessary conditions,operation process,precautions and so on. Through 4 years of operation,it proved that the application system was a safe and effective new mode of medical record management.
作者
梁玉梅
LIANG Yumei(Harbin 242 Hospital of A VIC, Harbin 150066)
出处
《航空航天医学杂志》
2018年第5期606-608,共3页
Journal of Aerospace medicine
关键词
电子病历
电子签名
无纸化
归档
质控
浏览
electronic medical records
electronic signature
paperless
filed
quality control
browse
