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电子病案的产生是人类在医院病案管理方面的一次重大革命,它将改变原来病案形成、收集、整理、归档、利用原始的病案管理格局,它的诞生与发展,无论是病案工作者的传统管理理念、管理方式、服务方式、还是病案使用者获取信息的方式方法等都将发生着根本性的变化,但在电子病案的安全性、保密性等技术问题和法律地位未得到认可与保证以前,电子病案与纸质病案管理共存的二元格局将会持续存在,并且两种共存状态下病案的社会属性和功能有所不同。电子病案的管理推动纸质病案管理的改革,纸质病案管理的经验和信息技术促进电子病案管理的规范和完善,两者之间相辅相成,其发展趋向是纸质病案管理功能的弱化和电子病案管理功能的强化。
The emergence of electronic medical records is a major revolution in human medical records management in the hospital. It will change the original medical record formation, collection, collation, filing, utilization of the original medical record management pattern, its birth and development, whether it is the traditional management of medical record workers Philosophy, management style, service mode, or the ways and means of obtaining information by medical record users will all change fundamentally. However, before the technical problems and legal status of the electronic medical records such as security and confidentiality are not recognized and guaranteed, The dualistic coexistence of electronic medical records and paper medical records will persist, and the social attributes and functions of the medical records in the two coexistent states will be different. The development of electronic medical records promotes the reform of paper medical record management, the experience of paper medical records management and the information technology promote the standardization and perfection of electronic medical records management. The two are mutually reinforcing. The development trend is the weakening of paper medical record management and electronic medical record Strengthen management functions.