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电子病案(Electronic Medical Record,EMR)的理论与实践已引起了我国医学界的广泛重视与认同,我院试行EMR以来,我们充分体会到了EMR带来的快速、方便和时效,同时也给病案管理工作者带来了巨大的冲击和挑战。怎样在传统的病案管理基础上尽快适应EMR带来的现代化病案管理模式,实现纸质病案向EMR管理的转轨,探索一条符合我国国情的病案管理模式,是摆在病案管理工作者面前的严峻课题。在此我们仅从病案管理方式的转型入手,谈一点EMR管理的粗浅体会。 一、EMR促使传统病案管理方式的现代转型
The theory and practice of Electronic Medical Records (EMR) have drawn widespread attention and recognition from medical circles in our country. Since EMR was piloted in our hospital, we have fully realized the rapid, convenient and time-efficient EMR brings, Workers have brought tremendous impact and challenge. How to adapt to the modern medical record management mode brought by EMR as soon as possible based on the traditional medical record management and to realize the transition from paper medical record to EMR management and to explore a medical record management model that is in line with China’s national conditions is a serious issue facing medical record management workers . Here we only start with the transition of the medical record management mode and talk about the superficial experience of EMR management. First, EMR promotes the modern transformation of traditional medical record management