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目的电子病案的发展是建设数字化医院的重要前提,了解国内外电子病案建设现状及发展趋势对电子病案建设工作有重要的指导意义。方法查阅大量的相关参考文献,总结归纳了国内外电子病案在病案信息输入、信息标准化和电子病案安全性三个方面取得的成果,在总结分析现有成果的基础上结合自己的认识,提出了电子病案将来可能的一个发展趋势。结果国内电子病案发展不论是在技术层面还是立法层面均落后于国外先进发达国家。结论电子病案的发展终将会朝着网络化、智能化的方向发展,成熟的电子病案系统是数字化医院的建设的一个重要基石。
Purpose The development of electronic medical record is an important prerequisite for building a digital hospital. It is of great significance to understand the current situation and development trend of electronic medical records at home and abroad for the construction of electronic medical records. Methods A large number of relevant references were consulted, and the achievements made in the input of medical record information, information standardization and electronic medical record security were summarized. At the same time, based on the summarization and analysis of existing achievements, Electronic medical records in the future may be a trend. As a result, the development of domestic electronic medical records lags behind advanced foreign countries both in terms of technology and legislation. Conclusion The development of electronic medical records will eventually move towards network and intelligence. The mature electronic medical records system is an important cornerstone of the construction of digital hospitals.