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病案系统记录患者到医院看病的全过程,也就是患者的疾病档案,是对整个诊疗救治护理过程的详细记录,是对患者就医期间(整个诊断、治疗、护理全过程)原始记载。是医护人员临床实践记录与经验的积累。随着计算机信息技术快速发展,逐渐被应用在医院的管理方面。计算机信息技术的应用到患者病案管理过程中,将患者从门诊首诊再到入院治疗整个过程中的病例信息及数据完全采用计算机信息技术记录,可提高医院工作效率及医院的综合管理能力[1-2]。经过国际电子病案
The record system records the whole process of the patient’s visit to the hospital, that is, the patient’s disease record, which is a detailed record of the entire treatment and care process and is the original record of the patient during the medical treatment (the whole process of diagnosis, treatment and care). Medical staff is the accumulation of clinical practice records and experience. With the rapid development of computer information technology, it has been gradually applied in the management of hospitals. The application of computer information technology to the patient medical record management process, the patient information from the first visit to the hospital outpatient treatment and treatment of the entire process of case information and data using computer information technology records, can improve the efficiency of the hospital and the hospital’s comprehensive management capabilities [1 -2]. After the international electronic medical record