CAJ | 학술논문

电子病历的管理是医院信息化建设的重要一部分。它的应用提高了医疗质量、提升了工作效率、改善了医疗信息的收集、分析、上报。自2011年医院推行电子病历系统以来，存在门诊信息非标准化、流程设置缺陷、纸质病历与电子病历内容不一致、电子病历未达质控要求、管理不到位、信息化建设不符合卫生部标准、培训不足等。要完善系统流程设置，优化信息整合，加强培训以逐步推动电子病历的发展，使其更好的为临床服务。
전자병력적관리시의원신식화건설적중요일부분。타적응용제고료의료질량、제승료공작효솔、개선료의료신식적수집、분석、상보。자2011년의원추행전자병력계통이래，존재문진신식비표준화、류정설치결함、지질병력여전자병력내용불일치、전자병력미체질공요구、관리불도위、신식화건설불부합위생부표준、배훈불족등。요완선계통류정설치，우화신식정합，가강배훈이축보추동전자병력적발전，사기경호적위림상복무。
Electronic medical record management is an important part of hospital information construction. The application of it, improve the medical quality, improve work efficiency, improve the medical information collection, analysis, reporting. Since the implementation of the electronic medical record system in hospital from 2011, we have found problems in the work practice such as outpatient information standardization unprepared, lack of communication during hospitalization, standardization is not good, flow setting defects, paper records and electronic medical record content is not completely consistent, the electronic medical record is not up to the quality control requirements, management does not reach the designated position, the informatization construction is not in accordance with the standard of ministry of public health, lack of training and so on. The electronic medical record problems gradually exposed. We should perfect the system flow setting, optimize information integration, strengthen the training to promote the gradual development of electronic medical record, make it better for clinical services.