摘要
电子病历的无纸化管理是现代医院信息化进程中的必然趋势。某院在实施病案无纸化管理的过程中,通过实施可靠的电子签名、有效的时间戳和建立信息安全、无纸化工作流程等规章制度,实现了电子病历的归档、电子病历阅览和电子病历复印等工作。通过实施无纸化电子病历,实现了共享患者的医疗信息资源,提高了医院各部门的工作效率,对提高医院医疗质量,加快医院信息化建设具有重要的意义。某院在无纸化病案实施过程中,存在着对病案质控功能不重视、电子病历归档不及时以及系统功能不完善等问题,必须引起重视并进一步的改进。
Paperless management of electronic medical records is an inevitable trend in the process of modern hospital information.In the process of carrying out paperless management of medical records,the hospital realized the archiving,reading and copying of electronic medical records by implementing reliable electronic signature,effective time stamp,establishing rules and regulations of information security and paperless workflow.Through the implementation of paperless electronic medical records,the medical information resources of patients are Shared,the work efficiency of various departments of the hospital is improved,and it is of great significance to improve the medical quality of the hospital and accelerate the construction of hospital information.During the implementation of paperless medical records in a hospital,there are some problems,such as not paying attention to the quality control function of medical records,not timely filing of electronic medical records and imperfect system functions,which must be paid attention to and further improved.
作者
石斌
刘春玲
Shi Bin;Liu Chunling(Department of Medical Record Statistics,Xuanwu Hospital of Capital Medical University,Beijing 100053,China)
出处
《中国病案》
2019年第11期1-2,31,共3页
Chinese Medical Record
关键词
无纸化
电子病历
归档
Paperless
Electronic medical records
Archiving
