医院无纸化电子病历建设研究  

Study of Hospital Paperless Electronic Medical Record Construction

作　　者：吴亚杰[1] 杨扬[1] 杨晓鹏[1] WU Ya-jie;YANG Yang;YANG Xiao-peng(Department of Information, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan 450052,China)

机构地区：[1]郑州大学第一附属医院信息处,河南郑州450052

出　　处：《中国医疗设备》2017年第2期151-153,共3页China Medical Devices

摘　　要：本文通过在近几年医院电子病历的无纸化建设实践过程中积累的一些经验和体会,对医院电子病历无纸化建设的现状进行了分析。提出了无纸化电子病历建设的技术要求,包括数据源、医疗过程、医患互签文书及外院病案的无纸化要求和电子病历的归档管理,总结了无纸化电子病历的实现保证。Based on the experience and understanding accumulated during the practice process of hospital paperless electronic medical records (EMR) construction in recent years, this paper analyzed the current situation of hospital paperless EMR construction. The author put forward the technical requirements including data source, medical process, mutual signing of informed consent and paperless medical records from other hospital and archive management of EMR, and summarized implementation assurance of paperless EMR.

关 键 词：电子病历 无纸化 数字认证 医患互签 归档管理 

分 类 号：R197.324[医药卫生—卫生事业管理]