电子病历存储归档方法及优势分析  

Filing of Electronic Medical Records and Its Advantage

作　　者：石会玲[1] 王玲勉[1] 任爱玲[1] 王丽端[1] 

机构地区：[1]中国人民解放军第251医院骨关节科,河北张家口075000

出　　处：《护理学报》2009年第5期29-30,共2页Journal of Nursing（China）

摘　　要：介绍了数字化医院管理模式下,电子病历存储与归档的方法:电子病历存储采用虚拟打印技术,利用各业务系统的打印功能,通过虚拟打印接口,将患者的病案资料调出,以PDF格式按ID号集中存储于电子病历归档服务器中;电子病历归档系统由护理文员审核辅临科室的检查检验项目、麻醉师的麻醉记录、经治医生的全部病程、护理文书的全部记录等各关口归档的电子病历是否齐全,审核无误后提取生成"电子病历登记卡",然后与其他病历一并"提交",系统自动传至服务器得以存储。认为病历电子化存储管理的优势有:节省了时间,提高了工作效率;归档后的病历采用权限控制、硬件密钥等安全技术,能更有效地控制病历的修改和打印,有效提高病案传输与运转中的安全性;无纸化存储可减少成本支出、减少浪费;提供便捷的病案检索方式;实现信息资源共享,增加患者直接护理时数;改变护理文书质控由环节控制代替终末控制;缩短病历归档时间,方便患者打印;病历实现公开制度,使医疗过程公开透明。电子病历存储方式不仅方便医护人员的日常工作,更为广大患者提供了便利,真正体现了"以患者为中心"的服务理念,提升了医院形象,带来了良好的社会效益,值得推广。This paper sums up the storing and filing of electronic medical records. With the virtual printing tech, the medical records can be stored in order of the serial number of the records in the server for electronic medical records in the form of PDF. The various check-up and test items by the related departments, the record of anesthetizing, the whole medical history recorded by the related doctors, the whole nursing records, etc. are all checked for completeness by the nursing clerk and after verification, the electronic medical record registration card will be generated. Electronic storing of medical records enjoys various advantages： It＇s time-saving and increases work efficiency; the various security tech such as access control and hardware key strengthens the file security; it reduces the cost by no-paper storing; it provides convenient way of file retrieval, realizes share of sources and thus increases the hours of direct nursing for patients; it changes the way of medical record quality control from end control to link control; it shortens the filing time and makes the printing more convenient; it also brings the open system of medical records and makes the medical process open and transparent. All in all, electronic storing of medical records, with its patient-centered philosophy, brings convenience not only to the medical staff but also the patients, enhances the hospital image and yields good social returns.

关 键 词：电子病历 无纸化存储 护理管理 

分 类 号：C931.3[经济管理—管理学] R47[医药卫生—护理学]