CAJ | 학술논문

目的探讨病房无纸化建设及无纸化电子病历建设的构成要素。方法实施基于临床路径的半结构化新型电子病历，解决电子病历系统与各子系统的通讯，支持医护移动查房，解决医患数字签名问题，满足患者查询健教需求，电子病历实施无纸化存储与管理。结果病房无纸化建设是一个系统工程，其关键是无纸化电子病历，只有解决了以上各种问题，病房全面无纸化才能成为可能。结论病房全面无纸化建设，有利于实现病历无纸化归档，降低医疗成本、提高工作效率、增加经济效益和社会效益。
목적탐토병방무지화건설급무지화전자병력건설적구성요소。방법실시기우림상로경적반결구화신형전자병력，해결전자병력계통여각자계통적통신，지지의호이동사방，해결의환수자첨명문제，만족환자사순건교수구，전자병력실시무지화존저여관리。결과병방무지화건설시일개계통공정，기관건시무지화전자병력，지유해결료이상각충문제，병방전면무지화재능성위가능。결론병방전면무지화건설，유리우실현병력무지화귀당，강저의료성본、제고공작효솔、증가경제효익화사회효익。
Objective To explore constituents of paperless construction content of hospital room and paperless electronic medical record (EMR) system.Methods We carried out semi-structured EMR based on clinical pathway, solved communica-tions between EMR and different subsystem, supported mobile ward round of doctorsand nurses, realized digital signature of doc-tors and patients, satisfied patients′requirement of inquest and health education, and at last, EMR was enforced paperless stor-age and management .Results Paperless model construction of ward was a systematic engineering , and its key point was paper-less EMR.Only problems when these problem are solved, could paperless model construction of ward be possible.Conclusion Comprehensive paperless model construction of ward can make paperless medical records come true, cut down medical cost, rai-ses working efficiency, increase economic returns and social benefits.