電子健康檔案新發(fā)展
CCHIT認證
New Developments in Electronic Health Records (EHR):
CCHIT Certification
China Hospital Information Network
Conference 2008
September 26-29, 2008 – Nanning, PRC
“EHR是以患者為焦點，不局限于一個提供者，可由多個為患者提供醫(yī)護服務的組織代
表患者積累的健康信息。
通過互用性的功能，EHR成為授權從任何記載患者醫(yī)療保健史的來源訪問信息的手段。
EHR的界限不是圍繞組織記載信息，而是圍繞患者和與他們健康相關的信息。雖然它
以患者為焦點，它主要由授權的醫(yī)護提供者管理和使用，并且在醫(yī)護過程中需要EHR
支持的醫(yī)護人員也可訪問EHR。”
“An EHR is patient-focused in that it is not limited by what a single provider
organization is able to accumulate on behalf of a patient under its care.
Through the capabilities of interoperability, an EHR becomes an
authorized means to access information from whatever sources have
chronicled the health care experience of a patient over time.
The boundaries of an EHR are built not around the organization
documenting the information but around the patient and his or
her health-related information. Though it is patient-focused, it is
managed and used primarily by authorized care providers, as well
as by members of their staff who have a need to access the EHR to
電子健康檔案(EHR)是由一次或多次會診形成的患者健康信息的縱向電子紀錄。這信息
包括患者人口統(tǒng)計、進度注釋、問題、療程、重要標志、過往病史、免疫、實驗室數(shù)據(jù)
和放射報告。EHR使臨床工作者的工作流程自動化并且簡潔化。EHR能形成臨床會診
完整的記錄-并且通過界面直接或間接地支持其他與醫(yī)護相關的活動-包括支持基于證
據(jù)的決策，質量管理和結果報告。
The Electronic Health Record (EHR) is a longitudinal electronic record of patient
health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems,
medications, vital signs, past medical history, immunizations, laboratory data and
radiology reports. The EHR automates and streamlines the clinician's workflow. The
EHR has the ability to generate a complete record of a clinical patient encounter - as
well as supporting other care-related activities directly or indirectly via interface -
including evidence-based decision support, quality management, and outcomes |
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