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电子病历及其管理 总被引：1，自引：0，他引：1
随着信息技术、网络技术的发展和计算机在医院管理中的应用,医疗活动逐步趋向于标准化、规范化和现代化。特别是电子病历的开发与应用,使病历的形成过程、存储方式及使用方法都发生了巨大变化。面对信息网络技术日益社会化的现实,医院档案部门应加强病历档案的网络化管理及信息资源 的开发与利用,更好地为医院各项工作提供完整、准确的病案信息服务,为维护医院与患者的合法权益服务。 一、现代电子病历同传统纸质病历的区别 电子病历和纸质病历,都是医院对患者病情诊断治疗的记录。两者既有许多共性,也存在一定的差异。电子病历的产生、形成、归档及其传送、存储、管理等均与传统的纸质档案所用的技术、方法不同。 相似文献
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一、电子病历的基本内涵电子病历是信息技术和网络技术在医疗领域应用的必然产物,是医院计算机网络化管理的必然趋势。电子病历(Computer-basedPatientRecord,简称CPR)是病人健康和医护状况的终身电子信息的载体,是客观、完整、连续的病情变化及诊疗经过的详细记载,是临床进行科学诊断治疗的基础资料。同时也是医疗纠纷中具有法律效力的重要证据。电子病历实质上是整个医院以病人为中心的计算机信息网络化。 相似文献
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电子病历是指医务人员在医疗活动过程中,使用医疗机构信息系统生成的文字、符号、图表、图形、数据、影像等数字化信息,并能实现存储、管理、传输和重现的医疗记录,是病历的一种记录形式。2010年4月1日,我国《电子病历基本规范(试行)》正式实 相似文献
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主要介绍日本电子病历档案的发展历程以及日本政府对电子病历的政策和规划,富士通公司的电子病历解决方案和日本未来电子病历档案的发展方向和趋势,希望可以对我国电子病历的发展和相关政策的制定提供一定的借鉴。 相似文献
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电子病历是信息技术和网络技术在医疗领域应用的必然产物，是医院计算机网络化管理的必然趋势。电子病历（Computer—based Patient Record，简称CPR）是病人健康和医护状况的终身电子信息的载体，是客观、完整、连续的病情变化及诊疗经过的详细记载，是临床进行科学诊断治疗的基础资料。同时也是医疗纠纷中具有法律效力的重要证据。电子病历实质上是整个医院以病人为中心的计算机信息网络化。 相似文献
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关注民生是时代赋予我们国家的重任。健全的医疗保障体系成为实现人民当家作主,保障公民民主权利的重要举措。随着医保改革的推进、公民民主意识的增强以及信息技术的发展,电子病案作为一种新兴的病案形式,作为医疗保险理赔与报销的重要原始凭证,在医疗保障体制改革中日益显示出优越性。本文试从电子病案的角色定位、利用的有利因素以及存在的发展瓶颈三方面进行阐述,以期达到对医保改革中电子病案的利用问题较为充分的了解。 相似文献
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Barbara A Epstein Nancy H Tannery Charles B Wessel Frances Yarger John LaDue Anthony B Fiorillo 《Journal of the Medical Library Association》2010,98(3):223-227
Question:
What is the process of developing a clinical information tool to be embedded in the electronic health record of a very large and diverse academic medical center?Setting:
The development took place at the University of Pittsburgh Health Sciences Library System.Method:
The clinical information tool developed is a search box with subject tabs to provide quick access to designated full-text information resources. Each subject tab offers a federated search of a different pool of resources. Search results are organized “on the fly” into meaningful categories using clustering technology and are directly accessible from the results page.Results:
After more than a year of discussion and planning, a clinical information tool was embedded in the academic medical center''s electronic health record.Conclusion:
The library successfully developed a clinical information tool, called Clinical-e, for use at the point of care. Future development will refine the tool and evaluate its impact and effectiveness. 相似文献13.
Elizabeth Connor Book Review Editor 《Medical reference services quarterly》2013,32(3):359-365
Transitioning to electronic health records (EHRs) provides an opportunity for health care systems to integrate educational content available on interactive patient systems (IPS) with the medical documentation system. This column discusses how one hospital simplified providers’ workflow by making it easier to order educational videos and ensure that completed education is documented within the medical record. Integrating the EHR and IPS streamlined the provision of patient education, improved documentation, and supported the organization in meeting core requirements for Meaningful Use. 相似文献
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电子健康档案是个人健康管理、医疗诊断、临床治疗的重要依据,其规范建设是推动我国国民健康和医疗卫生发展的重要手段之一。通过阐释电子健康档案内涵,梳理国内外个人电子健康档案建设概况,揭示常态化疫情防控背景下个人电子健康档案建设的意义及存在问题,提出加强制度保障、宣传教育、技术维护、自我管理等常态化措施,为实现健康中国战略提供信息基石。 相似文献
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Mindy Thuna 《Medical reference services quarterly》2013,32(2):232-233
This column reviews some of a solo librarian's experiences that led to involvement with the hospital Clinical Informatics Team. This included work on the electronic health record (EHR), computerized physician order entry (CPOE) system, development of order sets, and participation in the Physician Technology Committee. 相似文献
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Nanette J Welton 《Journal of the Medical Library Association》2010,98(3):217-219
The Health Sciences Library at the University of Washington initiated and continues to develop a role in the electronic medical record, starting with the development of the first integrated web-based interface, called MINDscape. An Integrated Academic Information Management System (IAIMS) grant in 1992 began the process, which also led to the development of a clinical medical librarian position. Over the years, the librarian''s role in the clinical environment became more established, and with the advent of clinical online resources, it offered further opportunities for librarians to provide the expertise needed to incorporate the appropriate resources. The collaborative journey continues as librarians, now able to directly access the EMRs, provide information about what resources to use and where best to place them and design how best to provide notes or feedback to clinicians. 相似文献
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It has been shown that accessing the patients’ own electronic health records (EHR) can enhance their medical understanding and provide clinically relevant benefits. However, languages that are difficult for non-medical professionals to comprehend are prevalent in the EHR notes. The valuable and authoritative information contained in the EHR is thus less accessible to the patients, who ultimately stand to benefit the most from the information. To address this challenge, we are developing a system to retrieve EHR note-specific online consumer-oriented health education materials. We explored several query generation methods to convert long EHR notes to effective queries, including topic models and key concept identification. Our experiments show that queries using key concepts identified by a learning based model with pseudo-relevance feedback significantly outperform the baseline system of using the full text note. 相似文献
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《Journal of Government Information》2002,29(5):319-331
Access to electronic records is dependent on the constantly changing and evolving computer technology. Unlike paper records that can survive for hundreds of years unless measures are taken to destroy them, electronic records do not persist unless deliberate steps are taken to preserve them. This paper suggests that most Israeli (and possibly other) government institutions naturally take steps to preserve electronic records necessary for their ongoing immediate operational needs. Nonimmediate or extraoperational needs, such as archiving according to state laws, are not given the fullest attention. To preserve the historical record of government institutions, computer systems must be designed and budgeted to comply with state archive laws and the long-term needs of society. 相似文献
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OAIS研究及对我国电子文件管理的启示 总被引：1，自引：0，他引：1