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病案无纸化归档管理是医院信息化建设发展的必然趋势。从病案内容无纸化和业务流程无纸化两个角度对系统功能需求进行分析,解决病案无纸化归档的关键技术及法律方面问题,提出了系统架构设计,包括基础数据层、接口层、业务层、存储层和数据共享层五个层次,并对各模块功能进行了详细描述。该系统的实施实现了医院病案全流程无纸化归档,有效提升医院病案管理水平。
Paperless medical records management is the hospital information construction and development of the inevitable trend. From the two aspects of paperless medical records and paperless business processes to analyze the functional requirements of the system to solve the key technical and legal aspects of medical recordless paperless filing system architecture design, including the basic data layer, interface layer, Business layer, storage layer and data sharing layer five levels, and each module functions were described in detail. The implementation of this system realizes the paperless archiving and filing of the entire hospital medical record and effectively improves the medical record management level in the hospital.