胸外科电子病历质量控制和管理中国专家共识(2024版)  

Chinese expert consensus on quality control and management of electronic medical records for thoracic surgery(2024 version)

作　　者：中国医师协会胸外科医师分会 海峡两岸医药卫生交流协会胸外科专业委员会 吴阶平医学基金会肺癌专业委员会 浙江省医师协会胸外科医师分会 福建省医师协会胸外科医师分会 姜杰 胡坚 耿国军[2] 汪路明[3] 汤明坤 徐金明[3] 朱晓雷 陈啸晗 叶峰[2] 王莺[3] 莫军军[3] 王辉[3] 米彦军[2] 叶冠志 Chinese Association of Thoracic Surgeons;Cross-Strait Medicine Exchange Association’s Thoracic Surgery Professional Committee;WU Jieping Medical Foundation’s Lung Cancer Professional Committee;Zhejiang Provincial Thoracic Surgeons Associations;Fujian Provincial Thoracic Surgeons Associations;Jiang Jie;Hu Jian

机构地区：[1]不详 [2]厦门大学附属第一医院 [3]浙江大学医学院附属第一医院

出　　处：《中华胸心血管外科杂志》2024年第12期705-715,共11页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：浙江省重点研发计划(2022C04030);国家重点研发计划(2022YFC2407303);浙江省肺部肿瘤诊治技术研究中心(JBZX-202007);国家自然科学基金面上项目(8247103511);福建省自然科学基金(2022J05301,2021J05284)。

摘　　要：电子病历的应用是现代医疗信息化的重要组成部分,也是提升医疗质量和安全性的关键环节。制定规范、标准的胸外科电子病历有利于规范诊疗流程、提高医疗效率、提升医疗质量、更好地保障患者安全;有利于标准化、结构化数据的采集和运用,推动临床决策和人工智能运用以及临床专科专病中心的建设。中国医师协会胸外科医师分会、海峡两岸医药卫生交流协会胸外科专业委员会、吴阶平医学基金会肺癌专业委员会、浙江省医师协会胸外科医师分会和福建省医师协会胸外科医师分会在充分考虑相关国家政策要求、信息标准以及临床应用实践难点、痛点和最新研究成果的基础上,探索电子病历创新路径;经过多方、多轮次专业的讨论、调研,制定《胸外科电子病历质量控制和管理中国专家共识(2024版)》,旨在为我国广大胸外科医师、信息从业人员提供住院电子病历建设和应用参考,促进胸外科领域信息化水平和医疗水平不断提升,助力健康中国建设。The application of inpatient electronic medical records(EMRs)is a crucial component of modern healthcare informatization,and also a key factor in improving medical quality and safety.Establishing standardized EMRs for thoracic surgery helps to standardize treatment processes,improve medical efficiency,enhance quality of care,and better ensure patient safety.It also facilitates the collection and use of standardized and structured data,promoting clinical decision-making,the application of artificial intelligence,and the development of specialized clinical centers.Considering relevant national policies,information standards,clinical practice challenges and latest research findings in thoracic surgery EMRs,Chinese Association of Thoracic Surgeons,Cross-Strait Medicine Exchange Association’s Thoracic Surgery Professional Committee,WU Jieping Medical Foundation’s Lung Cancer Professional Committee,Zhejiang Provincial Thoracic Surgeons Associations and Fujian Provincial Thoracic Surgeons Associations have explored innovative paths for EMRs development.Through multiple rounds of professional discussions and research,the"Chinese expert consensus on quality control and management of electronic medical records for thoracic surgery(2024 version)"was formulated.It aims to provide a reference for the construction and application of inpatient EMRs for thoracic surgeons and information professionals across China,promoting continuous improvement in the informatization and medical standards of the thoracic surgery field,and contributing to the construction of"healthy China".

关 键 词：电子病历 胸外科 质量控制 人工智能 专家共识 

分 类 号：R47[医药卫生—护理学]