电子病案实现无纸化需要解决的问题  

Problems Need to be Resolved in Paperless of Electronic Medical Records

作　　者：刘阳[1] 刘晋才[1] 

机构地区：[1]第三军医大学第三附属医院,重庆市400030

出　　处：《中国病案》2010年第10期50-50,47,共2页Chinese Medical Record

摘　　要：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 electronic medical records of No.1 military project have been applied for years,however,the electronic medical records and paper medical records are still the primary forms.The two forms of medical records are simultaneously present,which easily leads to inconsistent content,causes medical disputes,wasting manpower and material resources,increasing the economic burden of hospital,also does not conform to the present digital file preservation principle from National archives Bureau.Only realize the paperless of electronic medical records as soon as possible,these problems can be eliminated from the root.Problems related with electronic signatures,various consultation records,nursing records and putting laboratory sheets,imaging and pictures into electronic medical records need to be resolved.

关 键 词：军字一号工程 电子病案 无纸病案 

分 类 号：R197.324[医药卫生—卫生事业管理]