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电子病历系统是新型医疗体系的重要载体,在医院信息系统中占据核心地位。在医疗信息化建设水平高速发展的时代背景下,各医疗机构都已经或正在进行电子病历系统的开发实施。北京中医药大学东方医院通过实践经验和调研结果,总结归纳了电子病历开发实施中的关键问题,包括前期准备阶段领导的作用、预期目标、全局观念、专业化人员配备、患者唯一性身份认证、模板的制作和实施中的标准化实施、合法性和安全性保障、自动质控功能等方面。文章就这些问题进行了探讨。
Electronic medical records system is an important new medical system carrier, occupies a central position in the hospital information system. In the era of rapid development of medical informatization construction, all medical institutions have been or are carrying out the development and implementation of electronic medical record system. Based on the practical experience and research findings, Dongfang Hospital of Beijing University of Chinese Medicine summarized the key issues in the development and implementation of EHR, including the role of leaders during the preparatory phase, the expected goals, the overall concept, professional staffing, patient uniqueness authentication, Template production and implementation of the standardized implementation, legality and safety of security, automatic quality control functions and so on. The article discusses these problems.