【摘要】 目的随着医疗信息化技术的发展,医院病案室实施无纸化电子病案已成为发展趋势。方法探索模板设计,对住院病案建立CA(CA指电子商务中心)认证签名,通过质控、编码、归档、保存、调用、随访等七大基本流程进行管理。结果建立了适应无纸化管理要求的电子病案管理模式,使病案的形成过程、存储方式及使用方法都符合管理规范,力求达到节约资源、安全可靠、网络运作、快捷方便、资料完整、信息共享等要求。结论通过流程管理,无纸化电子病案管理运行良好,达到医院管理的要求。也证实无纸化电子病案的管理方法和经验是可行的。更多还原

【Abstract】 Objective With the development of medical information technology,the implement of non-paper medical record in medical record office has become a development trend.Methods To explore and design template,this paper suggests that build certificate authority signature for medical record, managing them through seven basic processes,such as,quality control,coding,filing,preserve,allocation and follow-up etc.Results It builds management mode of electronic medical record suitable for non-paper management requirement,making the forming process,storage mode and using methods of medical record accord with management regulations.It strives for the requirements of resource saving,safe and reliable,network operation,rapid and convenience,complete information and information sharing.Conclusions Through process management,non-paper electronic medical record management runs well and meets the qualification of hospital management.It proves that management method and experience of non-paper electronic medical record are feasible as well.更多还原