《电子病历在医院信息化发展中所发挥的重要作用》由会员分享，可在线阅读，更多相关《电子病历在医院信息化发展中所发挥的重要作用（13页珍藏版）》请在金锄头文库上搜索。
1、电子病历在医院信息化发展中所发挥的重要作用电子病历(electronic medical record,简称 EMR)是指核 算机化的病历，是指医护人员在医疗活动过程中，运用医 疗机构信息体系生成的文字、符号、图标、图形、数据、 印象等数字化信息，并能完成存储、办理、传输和重现的 医疗记载，是病历的一种记载方式。所谓病历是患者在医 院确诊医治全过程的原始记载，包含有主页、病程记载、 查看查验成果、医嘱、手术记载、看护记载等。而EMR是 依据特定体系的电子化患者记载。电子病历是信息技能和 网络技能在医疗范畴的必定产品，是医院病历信息化办理 的必定趋势，在临床的运用中极大地进步了医院的作业效 率和
2、医疗质量。The electronic medical record ( electronic medical record, referred to as EMR ) is refers to the accounting computerized medical records, refers to the medical staff in medical activities, text, symbols, icons, graphics, data, image digital information using medical information system generated
3、, and can complete the storage, management, transmission and reproduction of medical records, is a method of recording records. The medical records of patientsin the hospital diagnose cure is the whole process of the original records, contains the homepage, course records, check the inspection resul
4、ts, medication, operation records, nursing records. While the EMR is based on electronic patient record specific system. The electronic medical record is the information technology and network technology in the medical field must product, is the necessary trend of hospital information management, in
5、 the clinical application of greatly improve hospital service efficiency and quality of care.1.电子病历的运用现状The current situation of the use of 1 electronic medical records电子病历是核算机运用技能完成的信息化病历。与传 统手写病历比较，电子病历具有录入速度快、内在质量高、 易于保管、作业效率高级杰出特色。电子病历体系的运用 可进步医师的作业效率，一起为患者供给更安全、有用、 标准化的就医记载。跟着大家对效劳质量与法令意识的进 步，电
6、子病历作为描绘患者信息最完好的记载载体越来越 导致大家的注重。当前国内的电子病历体系的运用还处于初级阶段，许多仅仅对确诊、化验成果和药物医治等数据 进行了简略处置，远没有到达电子病历能够完成的真实功 用。当前的电子病历体系仅仅病历核算机办理化，而要到 达医院信息体系运用电子病历还有很大间隔。要真实完成 完好的电子病历体系，还有许多实际疑问需求处理。The electronic medical record is the computer skills to complete medical information. With the traditional hand-written medic
7、al records, electronic medical records with high input speed, high quality, easy storage, work efficiency high outstanding characteristics. Application of the electronic medical record system can improve the operation efficiency of physicians, together for patients with more safety, useful, standard
8、ization of medical records. Follow all awareness of service quality and legal progress, electronic medical records as depicted in patient information and record carrier the most intact more cause everybodys attention. Using the electronic medical record system at present is still in the primary stag
9、e, many only to the diagnosis, laboratory test results and medication data were simple disposal, far did not reach theelectronic medical record to complete the real function. The electronic medical record system currently only record accounting machine processing, and to reach a hospital information
10、 system and electronic medical records by using interval. To true complete electronic medical record system intact, there are many practical questions demand processing.2.电子病例在临床运用中的优缺点2 cases in clinical use of the advantages and disadvantages of电子病历体系首要面向临床医护人员，在运用过程中 表现出了其强壮的功用，但也有许多短少需求进一步完善， 归纳
11、详细内容如下：The electronic medical record system mainly for clinical staff, in the use of the process has showed its strong function, but also many of the need to further improve the induction, details are as follows:2.1电子病例在临床运用中的长处Strengths of the 2.1 electronic cases in clinical application(1) 病例录入灵敏、
12、便利、简略易学，彻底依照国家 卫生部病例书写标准需求，保管的电子病历传送信息疾速， 经过核算机网络在几分钟乃至几秒钟内就能把数据传往需 求的当地，完成长途存取患者病历。别的电子病历易存贮、 容量大、查阅便利。(1 ) case sensitive, convenient, easy to learn typing, completely in accordance with the national Ministry of health case writing standard requirement, the custody of the electronic medical record
13、 information quickly, after accounting network in a few minutes or even seconds can make the data is transferred to the local needs, complete the long-distance access patient records. Other electronic medical records, easy storage, large capacity, convenient access to.(2) 电子病例运用便利，电子病历体系便利检索和阅 读，患者就
14、诊时，不需求再供给他们的个人资料，例如过 敏史、药物史、医疗史等都可经过电子病历体系很简单获 取这些信息。经过体系能够便利、敏捷、精确地展开各种 研讨和统计剖析作业，省去了原始人为录入的繁琐作业， 大大削减作业量，极大地进步临床科研水平缓作业效率。(2 ) electronic case using the convenient, convenienthttp:/电子病历在医院信息化发展中所发挥的重要作用http:/ electronic medical records system retrieval and reading, patients, not demand to supply t
15、heir personal information, such as allergies, medication history, medical history, through the electronic medical record system is very simple to obtain such information. Through the system can be convenient, quick, accurate expansion of various research and statistical analysis of operation, elimin
16、ating the cumbersome operation primitive human input, greatly reducing the amount of work, greatly improve the clinical research level slow operation efficiency.(3) 电子病历安全牢靠，依据不一样的运用者描绘不 一样的权限，树立查阅、输入、修正和运用、分级授权等， 保证电子病历的安全性。一起，体系供给数据守时备份和 康复功用。可保证数据在受到破坏的情况下，得到最大极 限的康复。(3 ) the electronic medical record security firm, based on the use of different researchers describe different permissions, establish inspection
