It is a digital medical record saved, managed, transmitted and copied by electronic equipment (computers, health cards, etc.). ) instead of handwritten paper medical records.
Its content includes all the information of paper medical records. The National Institute of Medicine defines EMR as an electronic medical record based on a specific system, which provides users with the ability to access complete and accurate data, warnings, tips and clinical decision support systems.
With the networking of hospital computer management, the application of information storage media-CD-ROM and IC card, and the globalization of the Internet, separate medical records have appeared.
Electronic medical record is the inevitable product of information technology and network technology in the medical field and the inevitable trend of modern management of hospital medical records. Its preliminary clinical application has greatly improved the work efficiency and medical quality of hospitals, but this is only the beginning of the application of electronic medical records.
Electronic medical record is a digital patient medical record that is saved, managed, transmitted and copied by electronic devices (computers, health cards, etc.). ), rather than handwritten paper medical records. Electronic medical record has the characteristics of initiative, completeness and correctness, knowledge relevance and timeliness. It is a digital medical service record for medical institutions to guide and intervene outpatient and inpatient patients (or health care objects).