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目的研究电子病案作为医院信息系统的重要组成部分,它在实施过程中所遇到的困难及解决的方案。方法就电子病案采取的形式、疾病诊断的录入、医疗信息的共享等方面进行探讨。结果要保证医疗信息的共享与交流必须实现医学术语的标准化、搭建数据信息交换平台,提出要加快电子病案在我国的发展必须建立相关政策法规、加强对电子病案研发人员的培养。
Objective To study electronic medical record as an important part of hospital information system, its difficulties encountered in the implementation process and solutions. Methods to explore the form of electronic medical record, the diagnosis of disease input, medical information sharing and so on. Results To ensure the sharing and exchange of medical information, we must standardize medical terminology and set up a data exchange platform. We proposed that we must establish relevant policies and regulations to speed up the development of electronic medical records in our country and strengthen the training of electronic medical record research and development personnel.