CAJ | 학술논문

　　随着医院信息化的发展，单一的信息孤岛系统很难满足患者和医疗机构对完整信息链的需求。为此，需要构建统一完整的居民健康档案和跨医疗机构的信息共享机制，协同不同医疗机构的业务信息系统，实现居民电子病历和健康档案信息的共享和交换，为相关部门提供全面准确的决策支持。电子病历和电子健康档案是医院信息系统重要的两个组成部分。电子健康档案是电子病历的高级形式，有着电子病历无法替代的作用。它兼容患者医疗及个人健康保健、家庭健康档案、公共卫生信息、术后随访记录等信息，并实现居民健康档案多档合一。它实现了不同医疗机构的信息数据交流，利用更新及交互应用，可提高信息的使用率，是社区卫生服务的依据及全科医疗的工具，在区域卫生信息化建设中起着重要作用。重点介绍以电子病历为核心建立孕产妇的社区电子健康档案。
　　수착의원신식화적발전，단일적신식고도계통흔난만족환자화의료궤구대완정신식련적수구。위차，수요구건통일완정적거민건강당안화과의료궤구적신식공향궤제，협동불동의료궤구적업무신식계통，실현거민전자병력화건강당안신식적공향화교환，위상관부문제공전면준학적결책지지。전자병력화전자건강당안시의원신식계통중요적량개조성부분。전자건강당안시전자병력적고급형식，유착전자병력무법체대적작용。타겸용환자의료급개인건강보건、가정건강당안、공공위생신식、술후수방기록등신식，병실현거민건강당안다당합일。타실현료불동의료궤구적신식수거교류，이용경신급교호응용，가제고신식적사용솔，시사구위생복무적의거급전과의료적공구，재구역위생신식화건설중기착중요작용。중점개소이전자병력위핵심건립잉산부적사구전자건강당안。
With the development of hospital information, a single isolated islands of information system is difficult to satisfy the patients and medical institutions to complete information demand. Therefore, constructing the complete reunification of the resident health record and the medical institutions information sharing mechanism, coordination of different medical institutions of business information system, the realization of residents of electronic medical records and health information sharing and exchange, for the relevant departments to provide comprehensive and accurate decision support. Electronic medical record and electronic health record in hospital information system are the two most important part. Electronic health records is an advanced form of electronic medical records, electronic medical records have an irreplaceable role. It is compatible with medical and personal health, family health file, information on public health, chronic disease follow-up records and other information, and the realization of resident health record multiple files in one. It implements a different medical institutions information data exchange, using the update and interactive applications; it can improve the information utilization, is the basis for community health service, general medical tool, in the construction of regional health informatization plays an important role in. This paper introduces with electronic medical record as the core to establish maternal regional electronic health records.