结构化电子病历在临床管理中的应用  

Application of structured electronic medical records in the clinical management

作　　者：朱彦斌[1] 

机构地区：[1]陕西省延安市人民医院网络管理科,陕西延安716000

出　　处：《中国医药导报》2015年第35期161-164,共4页China Medical Herald

摘　　要：结构化电子病历已成为医疗活动信息的主要承载体,可作为医疗、教学、科研的第一手资料,更是成为医疗质量、技术水平、管理水平等方面综合评价的参考,对医院信息系统有着非常积极的推动作用。该系统将在规范医师病历书写、完善病历内容、避免缺项或漏项、提高病案质量等处发挥潜在作用,并且其对于医院日后的医学培训、科研数据的提取及分析等带来较大益处。结构化电子病历存在的问题主要为灵活性降低、结构化模板的制作过程专业性强工作量大、后续工作的不确定性。The structured electronic medical records has become the main bearer of the medical activity information, it can be used as medical treatment, teaching and scientific research of first-hand information, but also become the reference in comprehensive evaluation of medical quality, technical level and management level, the hospital information system has a very positive role in promoting. The system plays a potential role in the standard medical records writing, improve the medical record content, to avoid missing items or items, improve the quality of medical record, and has the benefits for its future medical training and scientific research of the hospital data extraction and analysis. The problems has existed the problem such as the structured electronic medical records mainly reduced flexibility, large work volume on the making process of the structural template specialized, the uncertainty of the follow-up work..

关 键 词：电子病历 结构化 临床管理 应用研究 

分 类 号：R197.32[医药卫生—卫生事业管理]