电子病案基本功能规范建设的实践与构想

Practice and Consideration of Standard Construction of Basic Functions of Electronic Medical Records

使用电子病案极大提升了医疗安全性、质量可控性,数据准确性和工作效率,减少人为因素的影响。随着应用的日益广泛,基本功能规范的缺失已成为影响电子病案发展的关键所在。建立规范化、标准化、科学化的电子病案规范已刻不容缓。

The use of electronic medical records has greatly increased the medical safety, quality control, data accuracy and work efficiency; besides, it has reduced the influence of human factors. With the increasingly wide applications of electronic medical records, the lack of basic functional criterion has bm＇ome the key to impact its development. Therefore, it is urgent to estabhsh a criterion of standard and scientific electronic medical records.