如何实现真正实用的电子病历  

Ways of implementing true and practical computer-based patient records

作　　者：张明[1] 刘雄飞[1] 郭文虎[1] 肖海[1] 

机构地区：[1]南京军区福州总医院,350025

出　　处：《中华医院管理杂志》2003年第4期222-225,共4页Chinese Journal of Hospital Administration

摘　　要：电子病历是医院数字化进程中的必然趋势 ,作者就电子病历的含义及其应具备的功能进行了分析。认为就电子病历本质而言 ,首先是“病历” ,必须具备传统病历的一切属性 ,其次才是“电子”这个表现形式和实现手段。提出了①必须用数据库 ,而不是以文本的方式来管理电子病历数据 ;②医生授权及安全控制方案 ;Computer based patient records(CPR) are an inevitable trend in the process of building digital hospitals. The authors offer an analysis of the implications and functions of CPR, arguing that in essence computer based patient records are first of all 'records', which must carry all the attributes of traditional records and that their 'electronic' form of expression and means of implementation are only of secondary importance. The following viewpoints are set forth: ①management of CPR data by means of databases rather than the text mode; ②adoption of authorization by doctors and the scheme of security control; ③implementation of the supplementary subensemble scheme.

关 键 词：电子病历 医院数字化进程 传统病历 安全控制方案 

分 类 号：R197.324[医药卫生—卫生事业管理]