摘要
目的介绍临床一体化电子病历系统的原理和功能,论述分析了临床一体化电子病历的应用价值和实施中需要注意的问题。方法将门诊、住院、医嘱、临床路径和临床护理一体化,以结构化的电子病历为核心搭建医院临床信息平台,将医院的临床、教学、科研等信息融合为一个有机整体。结果临床一体化电子病历系统可协助医护人员高效地完成日常诊疗活动,支撑医院电子病历评级和智慧医院评级,满足临床业务的信息化需求和以病人为中心的临床资源整合与利用的总体目标。结论该系统的设计具有较强的实用性,值得推广使用。
Objective To introduce the principle and function of the clinical integrated electronic medical record system,discuss and analyze the application value of the clinical integrated electronic medical record and the problems that need attention during implementation.Methods Integrating outpatient service,hospitalization,doctor’s order,clinical path and clinical care,build a hospital clinical information platform with structured electronic medical records as the core,and integrate the hospital’s clinical,teaching,scientific research and other information into an organic whole.Results The system can assist medical staff to efficiently complete daily diagnosis and treatment activities,support hospital electronic medical record ratings and intelligent hospital ratings,and meet the information needs of clinical business and the overall goal of patient-centric clinical resource integration and utilization.Conclusion The design of the system has strong practicability,so it is worthy of popularization.
作者
侯李萍
陈敏
HOU Li-ping;CHEN Min(School of Medicine and Health Management,Tongji Medical College,Huazhong University of Science and Technology,Wuhan,Hubei,430030,China)
出处
《中国医院管理》
北大核心
2021年第4期83-84,88,共3页
Chinese Hospital Management
关键词
临床一体化电子病历
架构设计
闭环管理
clinical integrated electronic medical record
architecture design
closed-loop management
