电子病历初级阶段病案管理的实践与思考

目前,我国医院的信息系统处在由管理信息系统向临床信息系统过渡的时期,医院电子病历的建设与发展尚处于初级阶段。为提高电子病历初级阶段的病案管理水平,笔者根据本院电子病历运行的实际情况,对电子病历初级阶段的病案管理进行总结和分析,并提出相应的措施,在关键问题上应引起足够的重视,为电子病历初级阶段的病案管理提供依据。

Practice and thinking of medical records management in the primary stage of electronic medical records

At present, the information system of hospital in China is in the period of management information system with the transition to a clinical information system, the construction and development with electronic medical record in hospital is still on the primary stage. In order to improve the level for management, the author summaries and analyzes the medical record management on the primary stage on the basis of actual conditions of the operation for electronic medical records in our hospital, and points out the corresponding measure, and it should be given the enough attention to the key problem to provide the basis for medical record management of electronic medical records on the primary stage.