目的:病历无纸化建设可以有效摒弃传统纸质病历保存固有的弊端:保存时效短、占据大量物理空间、查询及追溯困难等.方法:借助可信电子病案归档系统,通过各个临床业务系统改造,实现可信、合法、可追溯的病案归档.结果:实现临床病历、护理病历、检验检查报告、患者签字等病历文书的无纸化,实现病案可信归档和病案室集中管理.结论:无纸化不仅仅是对临床诊疗流程的梳理和完善,更是对医院管理水平的提高.%Objective:Paperless modifications of clinical medical records eliminate inherent disadvantages of traditional paper records,such as short storage life,huge storage space,inconvenient query and review,and etc.Method:All related clinical information systems have been reformed accordingly.With the help of credible electronic medical record archiving system,we realized the credibility,legality and traceability of medical records.Result:Paperless applications of clinical medical records,nursing records,medical check reports,medical informed consent achieve reliable medical records archiving and promote the management level of the medical record department.Conclusion:Full paperless applications not only rearrange and optimize clinical procedure,but also raise the management level in hospital.
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