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以电子病历为核心建立区域孕产妇电子健康档案的探讨
引用本文:陈磊,程蔚蔚,胡修全,彭永安. 以电子病历为核心建立区域孕产妇电子健康档案的探讨[J]. 中国数字医学, 2013, 0(8): 96-97,103
作者姓名:陈磊  程蔚蔚  胡修全  彭永安
作者单位:上海交通大学医学院附属国际和平妇幼保健院,200030,上海市衡山路910号
摘    要:随着医院信息化的发展,单一的信息孤岛系统很难满足患者和医疗机构对完整信息链的需求。为此,需要构建统一完整的居民健康档案和跨医疗机构的信息共享机制,协同不同医疗机构的业务信息系统,实现居民电子病历和健康档案信息的共享和交换,为相关部门提供全面准确的决策支持。电子病历和电子健康档案是医院信息系统重要的两个组成部分。电子健康档案是电子病历的高级形式,有着电子病历无法替代的作用。它兼容患者医疗及个人健康保健、家庭健康档案、公共卫生信息、术后随访记录等信息,并实现居民健康档案多档合一。它实现了不同医疗机构的信息数据交流,利用更新及交互应用,可提高信息的使用率,是社区卫生服务的依据及全科医疗的工具,在区域卫生信息化建设中起着重要作用。重点介绍以电子病历为核心建立孕产妇的社区电子健康档案。

关 键 词:区域电子健康档案  电子病历  孕产妇

Establish of Maternal Regional Electronic Health Records Based on Electronic Medical Records as Core
Affiliation:CHEN Lei, CHENG Wei-wei, HU Xiu-quan, et al( International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200030, P.R.C.)
Abstract:With the development of hospital information, a single isolated islands of information system is difficult to satisfy the patients and medical institutions to complete information demand. Therefore, constructing the complete reunification of the resident health record and the medical institutions information sharing mechanism, coordination of different medical institutions of business information system, the realization of residents of electronic medical records and health information sharing and exchange, for the relevant departments to provide comprehensive and accurate decision support. Electronic medical record and electronic health record in hospital information system are the two most important part. Electromc health records is an advanced form' of electronic medical records, electronic medical records have an irreplaceable role. It is compatible with medical and personal health, family health file, information on public health, chronic disease follow-up records and other information, and the realization of resident health record multiple files in one. It implements a different medical institutions information data exchange, using the update and interactive applications; it can improve the information utilization, is the basis for community health service, general medical tool, in the construction of regional health informatization plays an important role in. This paper introduces with electronic medical record as the core to establish maternal regional electronic health records.
Keywords:regional electronic health records  electronic medical record  maternal
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