面向病案管理新趋势的病案无纸化实现初探  

A Preliminary Study on the Realization of Paperless Medical Records Facing the New Trend of Medical Record Management

作　　者：刘蕾[1] 葛会香 刘彤晖[1] 安佰悦 董富国 罗文强[1] LIU Lei;GE Hui-xiang;LIU Tong-hui;AN Bai-yue;DONG Fu-guo;LUO Wen-qiang(Affiliated Hospital of Qingdao University,Qingdao,Shandong Province,266500 China)

机构地区：[1]青岛大学附属医院,山东青岛266500

出　　处：《中国卫生产业》2020年第32期65-67,共3页China Health Industry

摘　　要：随着医院规模的扩大和现有医疗水平的提升,病案在数量上和所蕴含的大量临床数据的使用需求也在与日俱增,传统的纸质病案由于其固有的载体属性,严重制约了病案的深度使用和医院现代化的发展。而随着医疗信息技术水平的提高,病案无纸化即电子病案已经成为病案发展的新趋势,如何实现病案的无纸化成为现代医院管理面临的新挑战。该文就病案无纸化面临的问题和实现的措施进行了探究。With the expansion of the scale of hospitals and the improvement of existing medical standards,the number of medical records and the use of large amounts of clinical data contained in them are also increasing.Traditional paper medical records have severely restricted medical records due to their inherent carrier properties.In-depth use and the modern development of hospitals were severely inhibited.With the improvement of medical information technology,paperless medical records,that is,electronic medical records,has become a new trend in the development of medical records.How to achieve paperless medical records has become a new challenge for modern hospital management.This article explores the problems and implementation measures of paperless medical records.

关 键 词：病案无纸化 电子病案 病案管理 

分 类 号：R19[医药卫生—卫生事业管理]