电子病历在随访及科研中的应用

Application of Follow-up and Research on Electronic Medical Record

复旦大学附属肿瘤医院利用电子病历系统,为每个门诊和住院病人建立统一标识,病人历次就诊和住院的电子病历均被关联该标识,实现了病人随访信息的自动登记,并建立科研病史,通过结构化病历实现了科研信息的收集与检索。

The Electronic Medical Record system in Cancer Hospital of Fudan University would generate a universal ID automatically for each outpatient or inpatient when he or she first came into the hospital. The medical records of every patient were indexed by the ID. When the outpatient who had ever been an in-patient came to see his or her doctor, his or her follow-up information was recorded automatically by the system. The EMR system also provided special medical records for research use. The Electronic Medical Record was also structurized. So the information of research medical records was captured by the system, then it can be searched by the EMR searching system.