住院病历无纸化系统的建设与应用  

Construction and Application of Paperless System of Inpatient Medical Records

作　　者：孙宇 王忱玉 戴维 SUN Yu;WANG Chenyu;DAI Wei(Cancer Hospital of China Medical University,Liaoning Cancer Hospital&Institute.Shenyang 110042,Liaoning,China)

机构地区：[1]中国医科大学肿瘤医院(辽宁省肿瘤医院),辽宁省沈阳市110042

出　　处：《中国卫生信息管理杂志》2023年第4期610-615,共6页Chinese Journal of Health Informatics and Management

摘　　要：目的提高病历管理的效率,解决传统病历管理模式的弊端。方法设计建设住院病历无纸化系统,运用可信电子签名、虚拟打印技术等实现住院病历的电子化归档管理,提供电子归档管理、PDF文件生成、电子病历逻辑校验、电子病历借阅、电子病历一键打印等功能。结果系统建成应用后,不仅可以有效降低人力成本,而且能提升病历管理的工作效率和内涵,降低病历管理的成本,提升患者的就医体验。结论传统纸质病历的管理流程已经改变,病历无纸化相关功能随着信息技术的不断推进而变得更加完善和便捷。Objective In order to improve the efficiency of traditional medical record management and solve the disadvantages of traditional medical record management mode.Methods The paperless system of inpatient medical records was designed and implemented.The electronic filing management of inpatient medical records was realized by using trusted electronic signature and virtual printing technology.The functions of electronic filing management,PDF file generation,electronic medical record logic verification,electronic medical record borrowing and electronic medical record one-click printing were provided.Results After the successful implementation of the system,it can not only effectively reduce the labor cost,but also improve the work efficiency and connotation of medical record management,reduce the cost of medical record management,and improve the patient's medical experience.Conclusion The management process of traditional paper medical records has also been changed,and the paperless related functions of medical records will become more perfect and convenient with the continuous advancement of information technology.

关 键 词：无纸化 电子病历 病历归档 病历复印 

分 类 号：R-058[医药卫生] R197.3