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电子病历基本规范试行解读
卫生部 《电子病历基本规范（试行）》
卫生部 《电子病历基本规范（试行）》
解读
解读
何雨生
何雨生
北京大学人民医院
北京大学人民医院
heyusheng@263.net
heyusheng@263.net
电子病历的定义
电子病历的定义
•国内定义：
•国内定义：
– 电子病历-EMR
– 电子病历-EMR
– 电子健康档案-EHR
– 电子健康档案-EHR
•电子病历与电子病历系统
•电子病历与电子病历系统
电子病历的定义(HIMSS白皮书2006)
电子病历的定义(HIMSS白皮书2006)
•Electronic Medical Record: An application environment composed of the
•Electronic Medical Record: An application environment composed of the
clinical data repository, clinical decision support, controlled medical
clinical data repository, clinical decision support, controlled medical
vocabulary, order entry, computerized provider order entry, pharmacy,
vocabulary, order entry, computerized provider order entry, pharmacy,
and clinical documentation applications. This environment supports the
and clinical documentation applications. This environment supports the
patient s electronic medical record across inpatient and outpatient
patient s electronic medical record across inpatient and outpatient
environments, and is used by healthcare practitioners to document,
environments, and is used by healthcare practitioners to document,
monitor, and manage health care delivery within a care delivery
monitor, and manage health care delivery within a care delivery
organization (CDO). The data in the EMR is the legal record of what
organization (CDO). The data in the EMR is the legal record of what
happened to the patient during their encounter at the CDO and is owned
happened to the patient during their encounter at the CDO and is owned
by the CDO.
by the CDO.
•Electronic Health Record: A subset of each care delivery organization s
•Electronic Health Record: A su
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