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面向住院的病案无纸化系统一体化建设及关键技术思考

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病案无纸化建设是医院迈向智能化病案管理发展的新阶段。实施病案无纸化对于提升病案管理效果、提高医疗服务水平以及降低医疗运行成本等方面具有显著的实际意义。为了探讨面向住院的病案无纸化建设的关键技术问题,本文首先总体性地梳理了病案无纸化建设在医院信息化系统中的整体定位和业务流程。其次,结合我院实际应用的病案无纸化情况,重点讨论了可信电子化签名、全维度病案数据校验等关键技术环节的核心难点和应用流程。然后,分析了病案无纸化的智能综合应用效果。最后,对病案无纸化的重点研究方向和未来发展模式进行了展望。
Integrated construction and key technological considerations of inpatient paperless medical record system
The construction of a paperless medical record system is a new stage in the development of intelligent medical record management in hospitals.The implementation of paperless medical records has significant practical significance in impro-ving medical record management,enhancing the level of medical services,and reducing healthcare operational costs.To explore the key technological issues of paperless medical record system for inpatient care,this article first provides an overview of the po-sitioning and business process of paperless medical record system in the hospital's information system.Secondly,based on the actual application of paperless medical records in our hospital,the core difficulties and application processes of key technological aspects such as trusted electronic signatures and comprehensive verification of medical record data from all dimensions are dis-cussed.Next,the integrated application effects of paperless medical records are analyzed.Finally,the key research directions and future development models of paperless medical records are discussed.

PaperlessElectronic signatureIntegrity verificationInpatient medical records

董雅儒、李海欣、李彭、周霏

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天津市肿瘤医院 天津 300060

无纸化 电子签名 完整性校验 住院病案

2024

现代医院
广东省医院协会

现代医院

影响因子:1.332
ISSN:1671-332X
年,卷(期):2024.24(7)