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军字一号工程的电子病案虽然使用多年,但仍以电子病案与纸病案两套储存形式运行。带来的问题是:(1)两套病案同时运行容易造成内容不一致引发医疗纠纷;(2)两套病案同时运行浪费医院人力物力增加医院经济负担;(3)两套病案同时运行不符合国家档案局目前对数字档案保存的原则。从根本上解决这些问题,需要尽快的实现无纸化电子病案。目前实现无纸化病案需要解决:(1)电子签名问题;(2)各种会诊单的问题;(3)护理记录的问题;(4)化验单、影像、图片存入电子病案的问题。
Although the military medical records on the 1st project have been used for many years, they still operate on two sets of electronic medical record and paper medical records. (2) The two sets of medical records run at the same time wasted hospital manpower and material resources to increase the hospital’s financial burden; (3) The two sets of medical records are not running simultaneously with the country Archives at present the principle of preservation of digital files. To solve these problems fundamentally, we need to realize a paperless electronic medical record as soon as possible. At present, paperless medical records need to be resolved: (1) electronic signatures; (2) questions of various consultation forms; (3) questions of nursing records; and (4) the problem of storing medical examinations, images and pictures in electronic medical records.