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随着现代化医学技术的迅猛发展,我院于2001年1月正式夸入了计算机网络化的高速公路,实现了全院临床科室全部采用计算机打印病案,下达医嘱,处理医嘱,非临床科室检查报告结果用网络传递。在运行一年多的过程中,我院医务处依据第四版《医疗护理技术操作常规》及医院信息管理系统医生工作站模块的设计要求,结合我院具体情况制定了《电子病案书写规范》下发科室,做到人手一册,为我院电子病案书写规范化、标准化提供了依据,统一了标准,规范了内容,形成了一套比较科学的电子病案新思路。
With the rapid development of modern medical technology, our hospital formally boasted a computer networked expressway in January 2001, realizing that all the clinical departments of the hospital use computer to print medical records, give medical orders, handle doctor’s orders, and report of examination of non-clinical departments The result is delivered online. In the course of more than one year of operation, the medical department of our hospital made the “Electronic Medical Records Writing Rules” in accordance with the design requirements of the fourth version of “General Medical Care Technology Operation” and the design of the workstation module of the hospital information management system doctor workstation. The department made a manpower manual, which provided the basis for standardization and standardization of electronic medical records in our hospital. It unified the standards and standardized the contents, and formed a set of new scientific ideas on electronic medical records.