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电子病历系统是通过计算机等电子设备为载体,对医院患者的诊疗活动进行数字化记录的软件。电子病历中详细记录了医嘱、病程、过敏史、影像检查结果、出院记录等多项医疗数据。电子病历完整、系统、科学地记录了患者身体健康情况以及历次就诊记录,通过一个维度将患者内部不同层次的信息有机的联系在一起。与传统的纸张病历相比,电子病历可以迅速实现不同时间、不同医院医疗信息的高效整合以及信息共享,为临床诊疗提供大量科学准确的信息,大大提高医院的服务效率。本文通过电子病历系统在医院信息管理系统中的应用情况进行简要分析,以期提高电子病历系统在临床中解决实际医疗问题的能力。
Electronic medical record system is through the computer and other electronic equipment as a carrier, the hospital patient diagnosis and treatment activities digitally recorded software. EHR recorded in detail the doctor’s orders, duration, history of allergies, imaging findings, discharge records and many other medical data. Electronic medical records complete, systematic and scientific record of the patient’s health status and the history of visits, through a dimension of different levels of internal information within the patient organically linked. Compared with the traditional paper medical records, electronic medical records can quickly achieve different time and different hospitals, high-efficiency medical information integration and information sharing, clinical diagnosis and treatment to provide a large number of scientific and accurate information, greatly improving the efficiency of hospital services. In this paper, a brief analysis of the application of electronic medical record system in hospital information management system is made in order to improve the ability of electronic medical record system to solve practical medical problems in clinical practice.