摘要
目的:总结医院电子病历系统的应用和实施经验,为科学构建数字化医院提供设计方案。方法:医院电子病历的建立以患者为中心,建立其住院病历、相关医嘱、各类检查以及检验报告等信息。结果:最终实现电子病历的统一标准,电子病历与医疗相关数据信息的无障碍交换,实现医院内部电子病历信息的集成和共享。结论:电子病历系统在医院的应用提升了临床工作效率,为临床决策提供了辅助功能。
Objective：To summarize the application of hospital electronic medical record system and implementation experience, for the scientific and reasonable construction of digital hospital provides design scheme. Methods： The electronic medical record to the patient as the center including the establishment of hospital medical records, doctor＇s orders, all kinds of inspection, inspection reports and other information. Results： The uniform ultimate implementation of electronic health record standard, electronic data from medical records and medical information barrier-free exchange, realize the integration and sharing of electronic medical records information inside the hospital. Conclusion： The electronic medical record system to improve the clinical efficiency in hospital application, provide auxiliary functions for clinical decision making.
出处
《中国医学装备》
2013年第12期76-78,共3页
China Medical Equipment
关键词
医院信息系统
电子病历
信息共享
信息化建设
Hospital information system
Electronic medical records
Information sharing
Information construction
