眼科专科门诊电子病历专家共识(2024)  

Expert consensus on electronic medical records for ophthalmology outpatients(2024)

作　　者：中国卫生信息与健康医疗大数据学会眼科专业委员会专家组 戴虹[2] The Ophthalmology Professional Committee of the Chinese Medical Information and Big Data Association;Dai Hong(不详;Department of Ophthalmology,Beijing Hospital,Beijing 100010,China)

机构地区：[1]不详 [2]北京医院眼科,北京100010

出　　处：《中华实验眼科杂志》2024年第7期593-601,共9页Chinese Journal Of Experimental Ophthalmology

基　　金：首都卫生发展科研专项(首发2020-2-4051)

摘　　要：眼科是专科化程度较高的科室,通用门诊电子病历无法满足其专科特殊业务需求。推行眼科专科门诊电子病历可规范诊治流程,提升病历产出效率,强化慢性眼病的进展监测,辅助诊疗决策。中国卫生信息与健康医疗大数据学会眼科专业委员会依据国家相关政策法规以及行业标准,结合通用门诊电子病历在眼科临床使用的痛点及眼科医生在临床诊疗、科研中的实际需求,经过认真、全面、充分讨论达成共识性意见,制定《眼科专科门诊电子病历专家共识(2024)》,旨在为眼科门诊电子病历的设计、应用和管理提供更加专业、精细和实用的载体。Ophthalmology is a highly specialized department,and universal outpatient electronic medical records cannot meet the special needs of the department.Electronic medical records for ophthalmic specialist outpatient department can standardize the process of diagnosis and treatment,improve the efficiency of medical record production,strengthen the progress monitoring of chronic eye diseases,and assist in diagnosis and treatment decision-making.The Ophthalmology Professional Committee of the Chinese Medical Information and big data Association,in accordance with relevant national policies,regulations,and industry standards,combined with the sore points of the use of universal outpatient electronic medical records in ophthalmology clinical practice and the actual needs of ophthalmologists in clinical diagnosis,treatment,and research,reaching consensus opinions after serious,comprehensive and thorough discussions,formulated the Expert consensus on electronic medical records for ophthalmology outpatients(2024),Intended to provide a more professional,refined,and practical carrier for the design,application,and management of electronic medical records in ophthalmic clinics.

关 键 词：电子病历 眼科专科门诊 临床诊疗 科研 设计 应用 管理 

分 类 号：R77[医药卫生—眼科]