电子病历在医院息化发展中所发挥的重要作用.docVIP

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, and can complete the storage, management, transmission and reproduction of medical records, is a method of recording records. The medical records of patients in the hospital diagnose cure is the whole process of the original records, contains the homepage, course records, check the inspection results, 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 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 medical 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 op