This part applies to the standardized capture, transmission, storage, and ****enjoyment exchange of admission and discharge records within 24 hours in the electronic medical record, as well as the development and application of information systems.
The medical record is the original record of the whole process of diagnosis and treatment of the patient in the hospital, which contains the first page, the record of the course of the disease, the examination and test results, the doctor's orders, the surgical record, the nursing record and so on. Electronic medical record (EMR) not only refers to the static medical record information, but also includes the provision of related services. It is electronically managed information about an individual's lifelong health status and healthcare behaviors, and involves all process information about the collection, storage, transmission, processing, and utilization of patient information. The National Institute of Medicine defines an EMR as an electronic patient record based on a specific system that provides users with access to complete and accurate data, alerts, reminders, and clinical decision support systems.
Electronic medical records emerged with the networking of hospital computer management, the use of information storage media - CD-ROMs and IC cards, and the globalization of the Internet. Electronic medical records is the inevitable product of information technology and network technology in the medical field, is the inevitable trend of modernization and management of hospital medical records, its initial application in the clinic, greatly improving the efficiency of the hospital and the quality of medical care, but this is still only the beginning of the application of electronic medical records.