病案资料无纸化归档系统的建立及应用  

Establishment of Paperless Medical Records Materials Archiving System and Its Application

作　　者：林琳[1] 王韬[1] 朱晓东[2] 

机构地区：[1]首都医科大学附属北京天坛医院信息中心,北京市100050 [2]首都医科大学附属北京天坛医院病案室,北京市100050

出　　处：《中国病案》2016年第1期4-6,共3页Chinese Medical Record

基　　金：国家高技术研究发展计划(863计划)数字化医疗医院示范课题经费支持

摘　　要：探讨针对医院信息系统,包括电子病历、HIS医嘱系统、LIS检验系统、PACS影像系统、移动护理等系统进行数字签名改造,即在各信息系统实现数字签名方式提交电子文书。将各个系统中具备数字签名的电子文书汇总到电子病历归档系统,实现电子病历无纸化归档,从而取消纸质病案。医院对2014年全年3万余份病案实施无纸化归档,基本实现电子病历无纸化改造。通过实际应用证明了基于电子签名的电子病案无纸化归档是安全的、可行的、有效的病案管理新模式。实现电子病历无纸化归档系统是电子病历无纸化的必经之路。To investigate the conduction of digital signature transformation aimed at the information system of the hospital, included electronic medical records, HIS system of medical advice, LIS checking system, PACS image system and moving nursing system and so on, which means to realize the application of digital signature method for the submit of electronic materials. To collect all the electronic materials with digital signature in each of the system into the electronic medical records archiving system, so as to realize paperless archiving of electronic medical records and cancel paper medical records. Through archiving more than 30,000 copies paperless electronic medical records in the whole year of 2014, we realized the paperless electronic medical records renovation basically.The paperless archiving of electronic medical records based on the digital signature is a safe, feasible and effective management mode of medical records through the practical application. The realization of paperless achieving system is the inevitable way to the paperless electronic medical records.

关 键 词：电子签名 电子病历 无纸化 归档 

分 类 号：R197.323[医药卫生—卫生事业管理]