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传统病历电子化的过程面临以下八个问题:①我国无电子病历的统一标准,使得信息难以整合与交换;②电子病历未得到法律上的认可,使其很难有序发展;③保密性存在较大漏洞;④存储空间小,难以满足病历反复使用的特点;⑤电子病历质量存在许多问题;⑥医护之间的脱节现象;⑦电子病历管理制度不完善增大了病案管理难度;⑧系统软硬件的配置问题。就以上问题,本文提出了如下解决办法:①制定我国电子病历管理办法;②建立电子病历的标准;③尽快立法,得到法律保障;④采取措施提高电子病历的安全性;⑤建立、健全质量监督控制机制;⑥培养提高医护人员素质。
The traditional electronic medical records process faces the following eight questions: ① China’s non-electronic medical records unified standards, making information difficult to integrate and exchange; ② electronic medical records are not recognized by law, making it difficult to orderly development; ③ the existence of confidentiality Large defects; ④ small storage space, difficult to meet the characteristics of repeated use of medical records; ⑤ There are many problems with the quality of electronic medical records; ⑥ the disconnect between medical care; ⑦ electronic medical records management system is not perfect and increase the difficulty of medical records management; Hardware configuration issues. On the above issues, this paper proposes the following solutions: ① the development of China’s electronic medical records management approach; ② the establishment of electronic medical records standards; ③ legislation as soon as possible, be protected by law; ④ take measures to improve the safety of electronic medical records; ⑤ establish and improve the quality of supervision Control mechanism; ⑥ training to improve the quality of health care workers.