门诊电子病历建设:现状与改进策略
作者:
作者单位:

(1.深圳市卫生健康发展研究和数据管理中心 深圳 518000;2.华中科技大学同济医学院医药卫生管理学院 武汉 430000;3.深圳市康宁医院 深圳 518000)

作者简介:

吴倩,硕士,助理研究员,发表论文2篇;通信作者:陈瑶,博士,副研究员。

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中图分类号:

R-058

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Construction of Outpatient Electronic Medical Records:Current Situation and Improvement Strategy
Author:
Affiliation:

(1.Shenzhen Health Development Research and Data Management Center, Shenzhen 518000, China;2.School of Medicine and Health Management of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China;3.Shenzhen Mental Health Center, Shenzhen 518000, China)

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    摘要:

    目的/意义 了解门诊电子病历建设的国际先进经验与我国实践现状,为完善门诊电子病历建设及质量管理提供参考。方法/过程 检索国内外文献数据库和国务院政策文件库,综述发达国家门诊电子病历建设经验、问题以及我国电子病历相关政策。结果/结论 我国门诊电子病历建设存在书写率偏低、病历质量不佳、数据应用不充分和共享壁垒高等问题。因此,须构建有效的病历质量监测体系与门诊电子病历数据应用平台。

    Abstract:

    Purpose/Significance To understand the international advanced experiences in the construction of outpatient electronic medical record (EMR) and the current practices in China, and to provide references for improving the construction and quality management of outpatient EMR. Method/Process By retrieving the domestic and foreign literature databases and the policy document databases of the State Council, the experiences and problems in the construction of outpatient EMR in developed countries and the relevant policies of China’s EMR are summarized. Result/Conclusion There are some problems in the construction of outpatient EMR in China, such as low writing rate, poor quality of medical records, insufficient data application, high sharing barriers, etc. Therefore, it is urgent to build an effective medical record quality monitoring system and outpatient EMR data application platform.

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引用本文

吴倩,卓丽军,陈芝芳,等.门诊电子病历建设:现状与改进策略[J].医学信息学杂志,2025,46(1):39-43

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  • 最后修改日期:2024-06-13
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  • 在线发布日期: 2025-02-12
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