电子病案与纸质病案共存的探讨

To Investigate the Coexistence of Electronic Medical Record and Papery Medical Record

病案是诊疗过程中具有法律效力的文字记录,也是各个医疗单位的重要档案资料,随着网络信息技术的不断发展,在医院信息系统已经广泛应用电子病案,与纸质病案比较,电子病案的应用和发展是一个非常大的进步。但目前,我国不能实现真正无纸化电子病案,纸质病案不能被完全的电子病案所取代,在今后一定时间内,电子病案与纸质病案将共同存在。本文分析了纸质病案的优劣势、电子病案的优劣势、纸质病案与电子病案并存的优劣势,并阐明随着医院不断深入发展信息化建设及计算机技术发展的日新月异,电子病案的应用成为医院医疗信息化发展的必然趋势,我们要将病案管理的观念更新,使病案管理的能力显著增强。

Medical records are a written record with the legal effect during the treatment process, but also an important data files of each medical unit. With the continuous development of network information technology, electronic medical records have been widely used in the hospital information system, and the application and development of electronic medical records are a very large improvement compared with papery medical records. But now, paperless electronic medical records can not be truely achieved in our country, papery medical records can not be completely replaced by electronic medical records, electronic medical records and papery medical records will co-exist in the future some time. This paper analyzes the advantages and disadvantages of papery medical records, electronic medical records and coexistence of electronic medical records and papery medical records, and clarify that the application of electronic medical records become the inevitable trend of the development of hospital medical information with the in-depth development of hospital information technology and rapid development of computer technology, we should update the data management idea, and make the records management capabilities enhanced significantly.