医院电子病历归档系统建设探索  

Exploration on the construction of EMR archiving system in hospital

作　　者：白雪 李乃适 王怡 BAI Xue;LI Naishi;WANG Yi(Medical Record Department of Peking Union Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China)

机构地区：[1]中国医学科学院北京协和医院病案科,北京100730

出　　处：《中国数字医学》2024年第12期58-64,共7页China Digital Medicine

基　　金：中央高水平医院临床科研业务费资助(2022-PUMCH-B-091)。

摘　　要：目的:解决纸质病历弊端,加快电子病历归档系统建设,助力医院高质量发展。方法:比较业务系统与归档系统的异同,分析归档系统建设的重要意义,从实践出发提出归档系统建设的关键环节,分享建设经验。结果:采用“3+2”模式逐步推进归档系统建设,经过2年多的建设已取得初步成效,梳理完成6项关键性要求,形成了包括基础功能、创新功能和特色功能在内的24项功能框架。结论:在大平台项目建设时,必须首先进行顶层设计,充分考虑其建设阻碍因素及建设关键性要求,并在实践过程中结合自身情况进行本地化开发部署。Objective To address the drawbacks of paper medical records,accelerate the construction of EMR(Electronic Medical Record) archiving system,and assist high-quality development of hospitals.Methods By comparing the similarities and differences between operation system and archiving system,the importance of the archiving system construction was analyzed,and the key links of archiving system construction were proposed based on practical experience,and construction experience was shared.Results The "3+2" mode was adopted to gradually promote the construction of the archiving system.After more than two years of construction,preliminary results were achieved,6 requirements have been sorted out and completed,and a functional framework was formed,such as basic functions,innovative functions,and distinctive functions.Conclusion In constructing large platform project,it is necessary to carry out top-level design first,fully consider its construction constraints and critical requirements,and carry out localized development and deployment based on its own situation in practice.

关 键 词：无纸化 电子病历 病历归档 

分 类 号：R197.3[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]