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2010年2月22日,卫生部印发了《电子病历基本规范(试行)》的通知,并于4月1日开始实施。《规范》中明确指出:电子病历是指医务人员在医疗活动过程中,使用医疗机构信息系统生成的文字、符号、图表、图形、数据、影像等数字化信息,并能实现存储、管理、传输和重现的医疗记录,是病历的一种记录形式。对于电子病历的实质和意义,很多业内同仁有着不同的看法。有人认为电子病历是纸质病历的电子化,是诊疗过程的记录,是分清责任的医学证据;有人认为电子病历是临床诊断、治疗和费用控制的基础,除病历质量控制之外,其意义在于医疗信息的共享、数据挖掘和辅助科研;还有人认为,电子病历是临床信息化的核心,是医院信息系统建设从“以财务和管理为中心”向“以患者和临床业务为中心”转移,从“以信息为重点”向“以知识为重点”转移的分水岭。笔者认为电子病历应该包括三个层面:首先,电子病历是对临床诊疗过程和数据的记录和共享。从这个层面上讲,电子病历首先要完成纸质病历的记录、证据和分享的职能。电子病历可以使病历书写规范化、保证医疗信息的完整性,有效提高工作效率和病历的质量,同时满足病历信息的检索、查询和共享。电子病历首先是病历,既然是病历就要遵从传统纸质病历的法规和规范。目前尽管国内对于电子病历颁布了一些规范和规定,但在电子病历的安全性、标准规范以及法律效力等方面还有待进一步改进和明确。
On February 22, 2010, the Ministry of Health issued the Notice on Basic Regulations on Electronic Medical Records (Trial) and started implementation on April 1. The “Code” made it clear that: EMR refers to medical personnel in the medical activities, the use of medical institutions, information systems generated by the text, symbols, charts, graphics, data, images and other digital information, and to achieve storage, management, transmission and Reproduced medical records, is a record of the medical record. Many people in the industry have different opinions about the nature and meaning of EHR. Some people think that electronic medical records are paper medical records of the electronic records of the process of diagnosis is to distinguish the responsibility of medical evidence; some people think that electronic medical records is the basis for clinical diagnosis, treatment and cost control, in addition to medical records quality control, the significance lies in Some people think that electronic medical records are the core of clinical informatization, and the construction of hospital information systems is mainly from the financial and management center to the patient and clinical business center “Transfer, from the” information-focused “to” knowledge-focused "transfer watershed. The author believes that electronic medical records should include three levels: First of all, electronic medical records is the clinical diagnosis and treatment process and data recording and sharing. At this level, EHRs must first fulfill the functions of recording, evidence and sharing of paper medical records. EHR can standardize medical records, ensure the integrity of medical information, effectively improve the work efficiency and the quality of medical records, at the same time, it can satisfy the retrieval, inquiry and sharing of medical records information. EMR is the first case of medical records, since it is necessary to comply with the medical records of traditional medical records laws and regulations. At present, although some domestic regulations and regulations on electronic medical records have been promulgated, the safety, standardization and legal validity of electronic medical records still need to be further improved and clarified.