Health records refer to the standardized and scientific records of residents' physical and mental health (normal health status, sub-health disease prevention, health protection and promotion, unhealthy disease treatment, etc.). It is an information resource that runs through the whole life process, covers all kinds of health-related factors, realizes multi-channel dynamic information collection, and meets residents' own needs and health management. Pomr (Problem-Oriented Medical Record) was first proposed by Weed et al. in 1968 in the United States, requiring doctors to adopt individual health problem-oriented records in medical services. The advantages are: individual health problems are concise, focused and clear, which is convenient for computer data processing and management. It has become the basic method to establish residents' health records in many countries and regions in the world.
Whether in China or developed countries, hospital informatization construction is a long exploration process. There are no and impossible finished products in HIS, CIS and GMIS systems, which must be constantly improved, updated and enriched in the application process. Compared with the informatization construction of other industries, the informatization of medical industry has its distinctive characteristics. Hospital information management must be patient-centered, patient information flow runs through the whole system, and all clinical business should be patient-centered; There are many kinds of hospital business, complicated management and frequent data exchange between business items; There is no general norm, standard and legal basis for hospital informatization, which increases the difficulty of data exchange with the outside of the hospital, and some application projects are difficult to carry out because of the lack of legal basis. I have been engaged in hospital information management for many years and summed up some experience in my work. Now I will discuss my personal views with all the friends present here.
So how to take the patient as the core, and the patient's information runs through the whole system business process or in what way? There is no doubt that the patient's electronic medical record must be established and run through the whole system.
Medical record is a comprehensive record of medical work, which objectively reflects the whole process of disease condition, examination, diagnosis, treatment and its results, and is an organic combination of all words, data, charts, images and other materials formed by medical personnel in the process of medical activities. Electronic medical record is to collect the patient's medical records into the computer through computer technology, and collect, analyze and sort out the relevant information of the medical records through the computer to form standardized information, thus improving the medical quality and professional level and providing help for clinical teaching, scientific research and information management. Electronic medical records can generally be interpreted as computerized medical record systems or computer-based medical records. In 199 1, the American medical computerization Committee pointed out that computerized medical records refer to electronic medical records stored in a system, which can support users to obtain complete and accurate information; Prompt and warn medical staff; Give clinical decision-making services; Connection management, books and periodicals catalogue, basic clinical knowledge and other equipment. Because the electronic medical record involves all aspects of the hospital and is highly complex, it not only refers to the static medical record information, but also includes the related services provided. It is not simply to computerize paper medical records, and it has more advantages than paper medical records.
However, electronic medical records have not found effective technical means in the description, integration, transmission and exchange of medical records information, which makes the development process of electronic medical records very complicated and technically difficult. However, the developed system has single function and poor universality, which makes the overall cost of electronic medical records high and difficult to be applied to medical systems on a large scale in a short time. From the legal point of view, the electronic medical record is only a copy of the patient's medical information, not a legal material, and it is difficult to become a legal basis when a medical dispute occurs. From the perspective of identity recognition, the promotion of electronic signature has little effect, and it is difficult to protect patients' data from being leaked. These unfavorable factors restrict the development of electronic medical records.
① The principle of gradual progress;
② Forward-looking principle of data collection;
③ Basic project dynamics principle;
④ Principle of objectivity and accuracy;
⑤ Principle of confidentiality.