论文部分内容阅读
病历档案主要是医护人员用于对医疗活动过程中所出现的各种医疗信息,其在出现医疗纠纷的过程中具有较高的法律效应,同时其也能够较为完整和真实地反应出患者在医院就医过程中病情的变化以及诊断治疗的各项情况。伴随着信息化技术的高速发展,医院影像系统(PACS)以及医院管理信息系统(HIS)的运用和建立,电子病历逐渐成为了医生工作站的核心,而在对病历进行管理时,大多数的医院还采取的是电子病历档案与纸质病历档案共存的方法来进行病案的管
Medical records are mainly used by health care workers for medical activities in the course of a variety of medical information that appears in the process of medical disputes with a high legal effect, but it also can be more complete and true response to patients in the hospital The medical condition during the change and the diagnosis and treatment of various conditions. With the rapid development of information technology, the application and establishment of PACS and HIS, EHR has gradually become the core of doctors’ workstations. When managing medical records, most hospitals Also taken is the electronic medical records file and paper medical records coexist ways to carry out medical records