门诊电子病历系统在医院中的应用  

Application of Outpatient Electronic Medical Record System in Hospital

作　　者：张强 赵磊 李刚 张丽荟 

机构地区：[1]北大医疗信息技术有限公司

出　　处：《中国数字医学》2014年第7期41-43,共3页China Digital Medicine

摘　　要：随着《电子病历系统功能规范》和《电子病历系统功能应用水平分级评价方法及标准》等规范的发布,越来越多的医院使用了电子病历系统,但大部分医院只局限于使用住院电子病历,门诊电子病历还在沿用手写的传统模式。基于门诊电子病历系统在某三甲医院上线的过程为背景,介绍了门诊电子病历特点,以及门诊电子病历帮助门诊医生解决的模板病历书写等一些实际问题。最后对新一代门诊电子病历系统提出一些新颖的病历自动形成等功能点,门诊电子病历的应用需要尽量符合门诊医生思维习惯,贴近门诊医生看诊过程,起到对门诊医生的辅助指导作用,为门诊电子病历系统的建设和应用提供指导。With the issuance of l：：unctional Specification of Electronic Medical Record System, Grading Evaluation Method and Standard of Function Application Level of the Electronic Medical Record System and other specifications, more and more hospitals use the electronic medical record system, but most hospitals are only confined to the use of electronic medical records of hospitalization. The electronic medical records of outpatient service still use the traditional model of handwriting. The electronic medical record system of outpatient is online in a Grade 3 and First-class hospital. With the background of this process, this paper introduces the characteristics of electronic medical records of outpatient service, and template medical record writing and practical problems solved by outpatient electronic medical records for outpatient doctors. Finally, some new medical record functions such as automatic forming of medical records are put forward for the new generation of outpatient electronic medical record system. The application of outpatient electronic medical records shall meet the thinking habit of outpatient doctors, be close to the diagnosis process of outpatient doctors, help and guide outpatient doctors, and provide guidance for construction and application of electronic medical record system of outpatient service.

关 键 词：门诊电子病历 CPOE 门诊医生工作站 病历结构化 

分 类 号：R319[医药卫生—基础医学] TP319[自动化与计算机技术—计算机软件与理论]