[转帖]电子病历及电子病历系统

danelchen

[这个贴子最后由danelchen在 2002/09/19 03:28pm 编辑]

电子病历及电子病历系统
"A CPR is electronically maintained information about an individual\'s lifetime health status and health care. The computer-based patient record replaces the paper medical record as the primary source of information for health care meeting all clinical, legal and administrative requirements. The CPR is supported by a system that captures, stores, processes, communicates, secures and presents information from multiple disparate locations as required."   
电子病历系统应具备病历的整合视野、知识库的存取应用、医嘱及临床资料之输入界面、整合的通讯支援及临床决策支援等功能。   
––未来的电子病历资料至少包含下列六种不同的格式：1.文字(Text,如SOAP、Progress Note等)。2.图形(Graphics,如临床医师手绘图形与手写注解等)。3.影像(Images,如X光、CT等)。4.数字(Numerical,如检验数据等)。5.声音(Sound，如心音、临床医师口述报告等)。6.影片(Full-motion video，如内视镜过程或手术过程记录等)

                               
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