[摘要] 针对目前电子病历档案管理的状况，阐述了病历档案管理规范和开发利用的必要性，提出了病历档案管理模式和开发利用工作，为医院病案管理工作、提高病历质量和医疗质量起到很好的促进作用。

    [关键词] 电子病历档案；规范管理；开发利用；病历质量

    [中图分类号]R197.3 [文献标识码]B [文章编号]1673-7210(2008)07(c)-105-02

    Standard management and utilization for electronic medical record

    CHEN Qiao-ling,LI Shao-ling, LUO Xiu-mei

    (Huizhou Municipal Central Hospital of Guangdong Province, Huizhou 516001,China)

    [Abstract] In this paper, the standard management and utilization for electronic medical record(EMR) are presented,and as a new idea that can promote the management of medical record and improve both the medical record quality and medical quality, the new management mode ofmedical record and utilization mode should be established according to the status of medical record management.

    [Key words] Electronic medical record;Standard management;Development and utilization;Quality of medical record

    电子病历档案是医务人员对病人进行问诊、查体、检查、诊断、治疗、护理等医疗过程中形成的文字资料的总和；它不仅是病人住院期间诊疗过程的真实反映 ......