电子健康档案新发展
CCHIT认证
New Developments in Electronic Health Records (EHR):
CCHIT Certification
China Hospital Information Network
Conference 2008
September 26-29, 2008 – Nanning, PRC
“EHR是以患者为焦点，不局限于一个提供者，可由多个为患者提供医护服务的组织代
表患者积累的健康信息。
通过互用性的功能，EHR成为授权从任何记载患者医疗保健史的来源访问信息的手段。
EHR的界限不是围绕组织记载信息，而是围绕患者和与他们健康相关的信息。虽然它
以患者为焦点，它主要由授权的医护提供者管理和使用，并且在医护过程中需要EHR
支持的医护人员也可访问EHR。”
“An EHR is patient-focused in that it is not limited by what a single provider
organization is able to accumulate on behalf of a patient under its care.
Through the capabilities of interoperability, an EHR becomes an
authorized means to access information from whatever sources have
chronicled the health care experience of a patient over time.
The boundaries of an EHR are built not around the organization
documenting the information but around the patient and his or
her health-related information. Though it is patient-focused, it is
managed and used primarily by authorized care providers, as well
as by members of their staff who have a need to access the EHR to
电子健康档案(EHR)是由一次或多次会诊形成的患者健康信息的纵向电子纪录。这信息
包括患者人口统计、进度注释、问题、疗程、重要标志、过往病史、免疫、实验室数据
和放射报告。EHR使临床工作者的工作流程自动化并且简洁化。EHR能形成临床会诊
完整的记录-并且通过界面直接或间接地支持其他与医护相关的活动-包括支持基于证
据的决策，质量管理和结果报告。
The Electronic Health Record (EHR) is a longitudinal electronic record of patient
health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems,
medications, vital signs, past medical history, immunizations, laboratory data and
radiology reports. The EHR automates and streamlines the clinician's workflow. The
EHR has the ability to generate a complete record of a clinical patient encounter - as
well as supporting other care-related activities directly or indirectly via interface -
including evidence-based decision support, quality management, and outcomes |
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