目的探讨电子病历为基础的临床医疗文书的建构,通过使用设计电子诊断证明代替目前手工填写门诊疾病诊断证明,实现门诊疾病诊断证明与电子病历信息共享,规范门诊出具疾病诊断证明管理。方法观察组使用电子诊断证明,以设计电子诊断证明模版、五个二的安全管理即两个告知、两个编码号、两个签名、两个核对、两处手填写措施,将电子诊断证明模版放在电子病历医疗文书中提供医师使用;对照组使用手工填写门诊疾病诊断证明,采取传统常规管理,统一印刷门诊疾病诊断证明提供使用。比较两组医师出具门诊疾病诊断证明合格率,使用统计学软件对合格证明与不合格证明数据进行统计分析。结果观察组与对照组出具门诊疾病诊断证明合格率分别为97.58%、82.26%,出具合格证明与不合格证明数据经统计软件分析,χ2=196.61、P=1.15E-44、P<0.05,具有统计学显著性差异。结论电子诊断证明代替手工填写门诊疾病诊断证明,实现电子诊断证明与电子病历信息共享,完善门诊出具疾病诊断证明医疗文书规范管理。? Objective To explore the construction of clinical medical documents based on electronic medical record by using the design electronic diagnosis certificate to replace the current manual diagnosis of outpatient disease diagnosis, to achieve outpatient disease diagnosis and electronic medical records information sharing, standard outpatient diagnosis and management of disease diagnosis issued. Methods The observation group used the electronic diagnosis certificate to design the electronic diagnosis certificate template. The safety management of the five two was informed by two numbers, two code numbers, two signatures, two check-ups and two hand-written measures. The electronic diagnosis certificate template On the medical records of electronic medical records, doctors were used. In the control group, diagnosis of outpatient diseases was completed by hand, and conventional diagnosis and management were used to diagnose the outpatient diseases. Comparing the two groups of doctors issued a diagnosis of outpatient disease pass rate, the use of statistical software on the proof of conformity and unqualified data for statistical analysis. Results The qualified rate of outpatient diagnosis in the observation group and the control group was 97.58% and 82.26% respectively. The data of certificate of conformity and non-conformity were analyzed by statistical software, χ2 = 196.61, P = 1.15E-44, P <0.05, Statistically significant difference. Conclusion The electronic diagnosis certificate instead of manual diagnosis of outpatient diagnosis of disease, to achieve the electronic diagnosis of electronic medical records and information sharing, improve outpatient diagnosis of medical documents issued by the certificate management. ?