摘要
我国电子化病历总体来说经历了3个阶段,即从纸质病历过渡到电子化、表格化,再过渡到目前的集成结构化。结构化的电子病历可以为临床科研等部门提供精确化的数据服务功能。构建临床研究一体化管理系统平台,可缩减临床病案的管理成本,提升临床电子数据的管理效率,规范流程。临床一体化管理系统的多点操作,跨院区访问、全流程、全过程的实时监控对数据的处理将是今后的发展方向。因此,文章就上述内容展开讨论。
China’s electronic medical records have generally undergone three stages,namely,from paper medical records to electronic and tabular medical records,and then to the current integrated structured medical records.Structured electronic medical records can provide accurate data service functions for clinical research and other departments.The construction of an integrated management system platform for clinical research can reduce the management cost of clinical cases,improve the management efficiency of clinical electronic data,and standardize the process.The multi-point operation of the clinical integrated management system,cross-hospital access,real-time monitoring of data processing in the whole process will be the future development direction.Therefore,this paper discusses the above content.
作者
顾捷飞
陈炜
Gu Jie-fei;Chen Wei(Shanghai Municipal Hospital of Traditional Chinese Medicine,Shanghai 200071,China)
出处
《科学与信息化》
2023年第21期159-161,共3页
Technology and Information
关键词
电子病历
全流程
设计构架
系统模块
electronic medical records
whole process
design framework
system modules
