电子病历基本规范试行解读.pdf

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