摘要
医院信息化建设是医改重要内容之一,病历无纸化作为电子病历建设的关键内容,在持续改善患者就医体验、提升管理效益、优化诊疗流程、规范医疗行为等方面具备明显优势,成为现代医院管理的必然趋势。文章以某三级甲等医院无纸化改造为例,针对无纸化实现过程中数据集成、电子签名、业务流程重塑、数据安全等问题,采用电子签名、时间戳等技术,重塑业务流程,建设住院病历无纸化系统,实现从数据采集、无纸化归档存储到管理和利用的全流程闭环管理。
The construction of hospital informatization is one of the crucial contents of medical reform.As the core aspect of the construction of electronic medical records,the paperless medical record boasts obvious advantages in continuously enhancing patients'medical experience,improving management efficiency,optimizing the diagnosis and treatment process,and standardizing medical behavior,which has turned into an inevitable trend in modern hospital management.Taking the transformation of paperless medical records in a tertiary first-class hospital as an example,targeting the issues of data integration,electronic signature,business process reengineering and data security during the realization of paperlessness,this paper adopts technologies such as electronic signature and timestamp to support to reengineer the business process and construct a paperless system for inpatient medical records,thereby achieving the closed-loop management of the entire process from data collection,paperless archiving and storage to management and utilization.
作者
董琼
曹岩
Dong Qiong;Cao Yan(The First Affiliated Hospital of Soochow University,Suzhou 215006,China)
出处
《办公自动化》
2025年第4期16-18,共3页
Office Informatization
关键词
电子病历
无纸化
病案归档
电子签名
electronic medical records
paperless
medical record filing
electronic signature
