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目的探讨病案信息化管理在现代化医院管理的建立与应用。方法通过讨论电子病案的概念、内容,病案作为医学信息储存和传递的载体,不但为医院内部的临床、教学、科研提供信息服务,而且需要向外提供有关的病案信息服务。电子病案系统是支持电子病案的一套软件硬件系统,它能实现病人信息的采集、加工、存储、传输、服务。结果电子病案的建立要求具有完整性、统一标准和一定基本格式,利用先进数据检索技术,进行快速检索查询资料,同时电子病案尚需显示出信息共享和通讯能力,易于存储,便于管理。结论在现代信息化医院管理中电子病案是HIS的基本保障,其开发与应用需要法律的认可,规范与标准化,技术与生成相结合,依照“总体规划、分步实施,逐块连接,不断完善”的原则进行组织实施。
Objective To explore the establishment and application of medical record information management in modern hospital management. Methods By discussing the concept, content and medical record of electronic medical record as the carrier of medical information storage and delivery, it not only provides information services for the clinical, teaching and scientific research in the hospital, but also needs to provide relevant medical record information service. Electronic medical record system is a set of software and hardware system that supports electronic medical records. It can realize the collection, processing, storage, transmission and service of patient information. Results The establishment of electronic medical record requires completeness, uniform standard and certain basic format. It uses advanced data retrieval technology to search and retrieve information quickly. At the same time, electronic medical records still need to show information sharing and communication ability, easy to store and manage. Conclusion In the modern informationized hospital management, electronic medical record is the basic guarantee of HIS. Its development and application need the recognition of law, standardization and standardization, and the combination of technology and production. In accordance with the overall planning, step by step implementation, continuous improvement "The principle of organization and implementation.