无纸化电子病案系统设计与实现  

Design and Implementation of Paperless Electronic Medical Records System

作　　者：刘琛玺[1] 彭传薇[1] 蔡丽璇[1] 张清霞 李天胜[1] 吴樱文 LIU Chen-xi;PENG Chuan-wei;CAI Li-xuan(General Hospital of Guangzhou Military Command of PLA,Guangzhou 510010,Guangdong Province,P.R.C.)

机构地区：[1]原广州军区广州总医院,广东省广州市510010

出　　处：《中国数字医学》2018年第8期49-52,共4页China Digital Medicine

摘　　要：目的:设计和实现基于第三方电子认证签名的无纸化电子病案系统,改变以往的纸质病案管理模式,持续提升病案管理质量和效率。方法:使用先进的计算机网络和第三方电子签名认证技术,对医院患者出院后的病案管理流程进行信息化改造,根据实际业务需要进行流程和功能设计。结果:完成了无纸化电子病案系统的设计与实现,并已在某三甲医院上线使用。结论:无纸化电子病案系统能够有效提高病案管理工作质量和效率,有效降低相关成本,是医院病案管理发展变革的必然方向。Objective： Design and implementation of paperless electronic medical records system based on certificate authority, which will change the traditional management pattern of papery medical records, and promote quality and efficiency persistently. Methods： Rebuilding and optimizing management process of medical records after discharging from hospital with advanced network technology and certificate authority. And designing workflows and functions according to actual businesses. Results： We have accomplished the paperless electronic medical record system and used the system in one grade III-A hospital. Conclusion： Paperless electronic medical record can promote quality and efficiency of medical records management and reduce related cost in hospital significantly. And it will must be the next direction of medical records management.

关 键 词：无纸化 电子病案 电子签名认证 病案管理 

分 类 号：R197.32[医药卫生—卫生事业管理] TP391[医药卫生—公共卫生与预防医学]