电子病案带来的思考

电子病案正在我国各级医院逐步推广。相对于传统的手工书写病历,电子病案有其书写方便快捷、信息传输及时安全、信息查找便捷、利于医院管理等优点,但在其应用过程中也渐显现出一些负面影响,如病案信息的真实性和准确性令人担忧,导致信息使用价值降低,耗资巨大,不利于青年医生的培养等,因此在建设和应用电子病案过程中,尚需考虑投资成本,应用科学完善的电子病案系统,循序渐进,分阶段实施,设第三方监管,保证病案信息的安全性,完善数据统计、分析功能等,以保证电子病案系统顺利开展。

Enlightenment from Electronic Medical Records

Electronic medical records are gradually extending in various hospitals.Compared with traditional hand-written medical records,although electronic medical records have a series of advantages,such as convenient and fast writing,timely and safe information transmission as well as conductive to management of hospitals,however,some negative effects,such as worrying authenticity and accuracy,gradually emerged,which lowers the value of information,weight against the cultivation to young physicians with prodigious expends.Thus,in the construction and application of electronic medical records,investment costs should be taken into account,scientific and improved electronic medical record system is applied in a phased and sequenced manner,surveillance of the third-party is also established to ensure the safety for information of medical records and improve the statistics and analysis of data for successful implementation of electronic medical record system.