《军队医疗机构电子病历管理办法》制订的原则和要点  

The EMR Regulation of Military Hospital:Principles and Key Points

作　　者：薛万国[1] 赵淑舫[1] 蒲卫[2] 郭进[2] 保鹏飞[1] 钱运宇[1] 

机构地区：[1]解放军总医院计算机室,北京100853 [2]总后勤部卫生部,北京100842

出　　处：《解放军医院管理杂志》2009年第12期1120-1122,共3页Hospital Administration Journal of Chinese People's Liberation Army

基　　金：项目得到军队卫生"十一五"面上课题资助(06L044)

摘　　要：针对医院的医疗记录电子化过程中存在的一些问题。总后卫生部组织制订了《军队医疗机构电子病历管理办法》。电子病历的合法性、病历真实性、病历质量、医疗安全、患者隐私保护等问题,本文主要介绍该管理办法制订过程中采取的保障医疗安全、保证病历质量、提高工作效率、保护患者隐私、维护病历合法性、兼顾信息化水平差异的应对原则及内容要点。During the process of electronic medical record（EMR） development,some problems have arisen.To conduct the application and development of EMR,The Health Department of General Logistics Department of PLA has enacted a regulation on EMR.Focused on the major problems of EMR legality,EMR originality,medical record quality,prevention of medical errors,protection of patient privacy,the author introduced the principles of the regulation as ensuring medical safety,maintaining MR quality,promoting efficiency,protecting patient privacy,keeping MR validity,balancing IT system difference.The content of this regulation was also outlined.

关 键 词：医院 电子病历 规范 军队 

分 类 号：R197.32[医药卫生—卫生事业管理]