摘要
目的电子病案的发展是建设数字化医院的重要前提,了解国内外电子病案建设现状及发展趋势对电子病案建设工作有重要的指导意义。方法查阅大量的相关参考文献,总结归纳了国内外电子病案在病案信息输入、信息标准化和电子病案安全性三个方面取得的成果,在总结分析现有成果的基础上结合自己的认识,提出了电子病案将来可能的一个发展趋势。结果国内电子病案发展不论是在技术层面还是立法层面均落后于国外先进发达国家。结论电子病案的发展终将会朝着网络化、智能化的方向发展,成熟的电子病案系统是数字化医院的建设的一个重要基石。
Objective The base of digital hospital is electronic medical record（EMR）.It＇s very important to know the situation and development trend of electronic medical record in the world.Methods A large amount of references were referred.The EMR achievements about information acquisition,information standardization and EMR security were collected and shew.A possible development trend of EMR was given after many references were studied.Results The technology and law of domestic EMR are behind developed countries.Many EMR works would be done by us.Conclusion The EMR would become intellectualized and networked.
出处
《中国病案》
2011年第8期29-31,共3页
Chinese Medical Record
关键词
电子病案
信息采集
信息标准化
病案安全
EMR
Information acquisition
Information standardization
EMR security
