医院无纸化电子病历建设研究

摘要

本文通过在近几年医院电子病历的无纸化建设实践过程中积累的一些经验和体会,对医院电子病历无纸化建设的现状进行了分析.提出了无纸化电子病历建设的技术要求,包括数据源、医疗过程、医患互签文书及外院病案的无纸化要求和电子病历的归档管理,总结了无纸化电子病历的实现保证.%Based on the experience and understanding accumulated during the practice process of hospital paperless electronic medical records (EMR) construction in recent years,this paper analyzed the current situation of hospital paperless EMR construction.The author put forward the technical requirements including data source,medical process,mutual signing of informed consent and paperless medical records from other hospital and archive management of EMR,and summarized implementation assurance of paperless EMR.