電(dian)子(zi)病歷(li)(li)(li)需要(yao)借助計算(suan)(suan)機(ji)設備(bei)轉(zhuan)變成可與(yu)人交互的信息形(xing)式(shi)，結合數(shu)據采(cai)集、記錄、加工、存(cun)儲、管理(li)、傳送等工作完成電(dian)子(zi)病歷(li)(li)(li)功(gong)能。這些工作是(shi)通過一套計算(suan)(suan)機(ji)系(xi)(xi)統(tong)(tong)(tong)來(lai)完成的，這個系(xi)(xi)統(tong)(tong)(tong)就(jiu)是(shi)電(dian)子(zi)病歷(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)。電(dian)子(zi)病歷(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)是(shi)電(dian)子(zi)病歷(li)(li)(li)依附存(cun)在(zai)的一種計算(suan)(suan)機(ji)系(xi)(xi)統(tong)(tong)(tong)，電(dian)子(zi)病歷(li)(li)(li)是(shi)電(dian)子(zi)病歷(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)的功(gong)能形(xing)式(shi)或功(gong)能統(tong)(tong)(tong)稱。由于(yu)比起"系(xi)(xi)統(tong)(tong)(tong)"概念，醫護人員更(geng)關心病歷(li)(li)(li)的內(nei)容，而且愿意具體化、形(xing)象化，所(suo)以通常模(mo)糊使用電(dian)子(zi)病歷(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)概念，不論是(shi)"系(xi)(xi)統(tong)(tong)(tong)"還是(shi)電(dian)子(zi)病歷(li)(li)(li)本身，都籠統(tong)(tong)(tong)稱為(wei)電(dian)子(zi)病歷(li)(li)(li)。電(dian)子(zi)病歷(li)(li)(li)具備(bei)哪些優勢？杭州(zhou)智慧**EMR特(te)點

萊文電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)系(xi)(xi)(xi)(xi)統(tong)以《電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)系(xi)(xi)(xi)(xi)統(tong)功能規范(fan)（試(shi)行）》、《電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)系(xi)(xi)(xi)(xi)統(tong)功能應用(yong)水平分級評(ping)(ping)價方法及(ji)標準（試(shi)行）》要求為參照進行，能夠不(bu)同類型**電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)分級評(ping)(ping)審需(xu)求，是(shi)臨(lin)床(chuang)業務系(xi)(xi)(xi)(xi)統(tong)的(de)中心。系(xi)(xi)(xi)(xi)統(tong)包括(kuo)門診電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)、住(zhu)院電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)、護理(li)(li)電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)區、專科電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)、**文書、病(bing)(bing)歷(li)質控、病(bing)(bing)歷(li)管(guan)理(li)(li)、無紙(zhi)化病(bing)(bing)案管(guan)理(li)(li)系(xi)(xi)(xi)(xi)統(tong)、臨(lin)床(chuang)決策支持系(xi)(xi)(xi)(xi)統(tong)（CDSS）等(deng)子(zi)(zi)(zi)(zi)系(xi)(xi)(xi)(xi)統(tong)，提(ti)供完整(zheng)、規范(fan)的(de)電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)管(guan)理(li)(li)功能。萊文電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)系(xi)(xi)(xi)(xi)統(tong)支持將(jiang)電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)以PDF格(ge)式輸出(chu)存(cun)儲，嚴格(ge)控制嚴禁篡改、隱匿、偽造(zao)、**奪(duo)、**取和毀壞電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)，確保電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)的(de)**性。符合《電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)基(ji)本規范(fan)》第(di)十三(san)條。杭州(zhou)智慧**EMR特點(dian)電(dian)(dian)(dian)(dian)子(zi)(zi)(zi)(zi)病(bing)(bing)歷(li)系(xi)(xi)(xi)(xi)統(tong)采用(yong)了結構化、模塊化結構設計(ji)。

電(dian)子(zi)病(bing)(bing)歷(li)的(de)(de)(de)(de)主要作用體現(xian)在以下幾個方(fang)(fang)面(mian)：提(ti)(ti)高(gao)**效(xiao)(xiao)率：電(dian)子(zi)病(bing)(bing)歷(li)系統允許(xu)醫生快速錄入(ru)、檢(jian)索和(he)(he)(he)瀏覽患(huan)者(zhe)的(de)(de)(de)(de)**信(xin)(xin)(xin)息(xi)(xi)，減(jian)少了(le)(le)手(shou)工書寫病(bing)(bing)歷(li)的(de)(de)(de)(de)時間，使醫生能夠(gou)更專注于患(huan)者(zhe)的(de)(de)(de)(de)診斷和(he)(he)(he)診療(liao)。同時，電(dian)子(zi)病(bing)(bing)歷(li)系統還(huan)支(zhi)(zhi)持(chi)多科室信(xin)(xin)(xin)息(xi)(xi)共(gong)享(xiang)，避免了(le)(le)信(xin)(xin)(xin)息(xi)(xi)的(de)(de)(de)(de)重(zhong)復(fu)錄入(ru)，提(ti)(ti)高(gao)了(le)(le)整體**工作效(xiao)(xiao)率。提(ti)(ti)升**質量：電(dian)子(zi)病(bing)(bing)歷(li)系統提(ti)(ti)供了(le)(le)完(wan)整、準(zhun)確的(de)(de)(de)(de)患(huan)者(zhe)**記錄，包括病(bing)(bing)史、診斷、診療(liao)方(fang)(fang)案等，為(wei)醫生提(ti)(ti)供了(le)(le)詳細的(de)(de)(de)(de)參考信(xin)(xin)(xin)息(xi)(xi)，有助(zhu)于提(ti)(ti)高(gao)診斷的(de)(de)(de)(de)準(zhun)確性和(he)(he)(he)診療(liao)的(de)(de)(de)(de)效(xiao)(xiao)果。此外，系統還(huan)支(zhi)(zhi)持(chi)智能化提(ti)(ti)醒和(he)(he)(he)輔助(zhu)決策功能，進一(yi)步降低了(le)(le)**差錯(cuo)的(de)(de)(de)(de)風(feng)險(xian)。便于信(xin)(xin)(xin)息(xi)(xi)管理(li)(li)和(he)(he)(he)科研：電(dian)子(zi)病(bing)(bing)歷(li)系統使得病(bing)(bing)歷(li)信(xin)(xin)(xin)息(xi)(xi)的(de)(de)(de)(de)存儲、檢(jian)索和(he)(he)(he)分析(xi)變得更加便捷。**機構可以輕松(song)地(di)管理(li)(li)大(da)量的(de)(de)(de)(de)病(bing)(bing)歷(li)數據，進行數據挖掘(jue)和(he)(he)(he)分析(xi)，為(wei)臨床研究和(he)(he)(he)科研提(ti)(ti)供有力的(de)(de)(de)(de)支(zhi)(zhi)持(chi)。支(zhi)(zhi)持(chi)法(fa)(fa)律舉(ju)證：病(bing)(bing)歷(li)是具有法(fa)(fa)律效(xiao)(xiao)力的(de)(de)(de)(de)醫學(xue)記錄。電(dian)子(zi)病(bing)(bing)歷(li)系統通過提(ti)(ti)供規范、完(wan)整的(de)(de)(de)(de)病(bing)(bing)歷(li)記錄，避免了(le)(le)書寫潦草、缺頁、漏項等問題，為(wei)**事故(gu)鑒定、**糾(jiu)紛爭議(yi)提(ti)(ti)供了(le)(le)有力的(de)(de)(de)(de)法(fa)(fa)律依據。

萊文(wen)電子病(bing)(bing)(bing)(bing)歷(li)(li)文(wen)書(shu)模(mo)板(ban)采用公(gong)司自主(zhu)研發的(de)(de)(de)模(mo)板(ban)編輯器，各(ge)類病(bing)(bing)(bing)(bing)歷(li)(li)和打印模(mo)板(ban)都以(yi)靈活(huo)的(de)(de)(de)模(mo)板(ban)形式(shi)展(zhan)現，能在很(hen)大程度上規(gui)范(fan)病(bing)(bing)(bing)(bing)歷(li)(li)書(shu)寫的(de)(de)(de)格(ge)式(shi)，病(bing)(bing)(bing)(bing)歷(li)(li)采集的(de)(de)(de)數(shu)據項和內容(rong)符合**衛生(sheng)部統(tong)一規(gui)定，又能根據醫(yi)生(sheng)的(de)(de)(de)不同需求不同語(yu)言(yan)習慣組織病(bing)(bing)(bing)(bing)歷(li)(li)模(mo)板(ban)，有(you)(you)效加快了醫(yi)生(sheng)書(shu)寫病(bing)(bing)(bing)(bing)歷(li)(li)的(de)(de)(de)質(zhi)量(liang)和速度，確保醫(yi)生(sheng)有(you)(you)更多的(de)(de)(de)時間投入到患(huan)者服務中(zhong)去。模(mo)板(ban)中(zhong)所(suo)有(you)(you)的(de)(de)(de)數(shu)據元素都可以(yi)與**頒布的(de)(de)(de)標(biao)準數(shu)據集相(xiang)對應，為區(qu)域健康檔(dang)案(an)共享提供基(ji)礎(chu)。符合《電子病(bing)(bing)(bing)(bing)歷(li)(li)基(ji)本規(gui)范(fan)》第七條、第十一條。電子病(bing)(bing)(bing)(bing)歷(li)(li)可記錄的(de)(de)(de)內容(rong)包(bao)括(kuo)：病(bing)(bing)(bing)(bing)人的(de)(de)(de)姓名、性別等自然(ran)信息。

所謂電子(zi)(zi)(zi)病(bing)(bing)歷是指**機構(gou)(gou)對(dui)(dui)門診(zhen)、住(zhu)院患(huan)(huan)者(zhe)臨床(chuang)(chuang)診(zhen)療和(he)(he)指導干預的(de)、數字化的(de)**服(fu)務(wu)工作記錄(lu)，是居民(min)個(ge)人在**機構(gou)(gou)歷次就(jiu)診(zhen)過(guo)程中(zhong)產生(sheng)和(he)(he)被記錄(lu)的(de)完整、詳細的(de)臨床(chuang)(chuang)信(xin)(xin)息(xi)(xi)資(zi)源。電子(zi)(zi)(zi)病(bing)(bing)歷不(bu)等同于(yu)**信(xin)(xin)息(xi)(xi)系(xi)統，它重(zhong)(zhong)點(dian)針對(dui)(dui)個(ge)人在**機構(gou)(gou)接受各(ge)類**服(fu)務(wu)的(de)過(guo)程中(zhong)產生(sheng)的(de)臨床(chuang)(chuang)診(zhen)療和(he)(he)指導干預信(xin)(xin)息(xi)(xi)的(de)數據集成系(xi)統，是**信(xin)(xin)息(xi)(xi)系(xi)統的(de)有機組成部分(fen)(fen)。目前，不(bu)少**電子(zi)(zi)(zi)病(bing)(bing)歷還沒有實(shi)(shi)現互(hu)聯(lian)互(hu)通(tong)，患(huan)(huan)者(zhe)在某(mou)個(ge)**、診(zhen)所就(jiu)診(zhen)，也做(zuo)了(le)(le)(le)一些(xie)基本(ben)檢查(cha)，但想(xiang)去另一家(jia)**機構(gou)(gou)再(zai)看(kan)病(bing)(bing)時，往(wang)往(wang)被要(yao)求在本(ben)院再(zai)次檢查(cha)。這樣的(de)重(zhong)(zhong)復檢查(cha)增加了(le)(le)(le)患(huan)(huan)者(zhe)的(de)麻煩，增加了(le)(le)(le)經濟負擔，也不(bu)利于(yu)分(fen)(fen)級(ji)診(zhen)療的(de)推廣。電子(zi)(zi)(zi)病(bing)(bing)歷備受**和(he)(he)醫生(sheng)青睞(lai)，其優(you)勢(shi)毋庸置疑。在中(zhong)國，多重(zhong)(zhong)聲音呼吁，各(ge)**電子(zi)(zi)(zi)病(bing)(bing)歷要(yao)做(zuo)到互(hu)聯(lian)互(hu)通(tong)，實(shi)(shi)現患(huan)(huan)者(zhe)診(zhen)斷信(xin)(xin)息(xi)(xi)共享，避免重(zhong)(zhong)復檢查(cha)，降低**費(fei)用(yong)，助力分(fen)(fen)級(ji)診(zhen)療。電子(zi)(zi)(zi)病(bing)(bing)歷的(de)應用(yong)能夠有效避免**錯(cuo)誤、降低成本(ben)、提高服(fu)務(wu)質(zhi)量。病(bing)(bing)人的(de)病(bing)(bing)歷信(xin)(xin)息(xi)(xi)需要(yao)長期保存，通(tong)過(guo)電子(zi)(zi)(zi)病(bing)(bing)歷即可(ke)實(shi)(shi)現。杭州智慧**EMR特點(dian)

電子病歷系統具備**違(wei)規警告(gao)功(gong)能，可以避免**錯(cuo)誤。杭州智慧**EMR特(te)點

萊文電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)以《電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)功能(neng)規范（試行(xing)(xing)(xing)）》、《電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)功能(neng)應用水(shui)平分級評(ping)價方法及標準(zhun)（試行(xing)(xing)(xing)）》要求為參照(zhao)進行(xing)(xing)(xing)，能(neng)夠(gou)不同類型**電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)分級評(ping)審(shen)需求，是臨(lin)床(chuang)(chuang)業務系(xi)(xi)統(tong)(tong)(tong)的(de)中心(xin)。系(xi)(xi)統(tong)(tong)(tong)包(bao)括(kuo)門診電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)、住院(yuan)電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)、護理(li)(li)電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)區、專(zhuan)科電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)、**文書、病(bing)(bing)(bing)歷(li)(li)(li)(li)質控、病(bing)(bing)(bing)歷(li)(li)(li)(li)管理(li)(li)、無紙化病(bing)(bing)(bing)案管理(li)(li)系(xi)(xi)統(tong)(tong)(tong)、臨(lin)床(chuang)(chuang)決(jue)策支持系(xi)(xi)統(tong)(tong)(tong)（CDSS）等子(zi)系(xi)(xi)統(tong)(tong)(tong)，提供完(wan)整、規范的(de)電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)管理(li)(li)功能(neng)。萊文電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)系(xi)(xi)統(tong)(tong)(tong)支持將電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)以PDF格式(shi)輸出(chu)存儲，嚴格控制嚴禁(jin)篡改、偽造、隱匿、**奪、**取(qu)和(he)毀(hui)壞電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)，確保(bao)電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)的(de)**性。符合《電(dian)(dian)(dian)(dian)(dian)(dian)子(zi)病(bing)(bing)(bing)歷(li)(li)(li)(li)基(ji)本規范》第十三條。杭州智慧**EMR特點(dian)