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上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則

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上海市衛(wèi)生局
2011 年10 月
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
I
目錄
第一篇概論篇..........................................................................................1
前言.............................................................................................................2
第 1 章電子病歷應(yīng)用的總體要求 ......................................................3
1.1 電子病歷的基本概念...............................................................................3
1.2 電子病歷的應(yīng)用目的...............................................................................3
1.3 電子病歷的應(yīng)用目標(biāo)...............................................................................3
1.4 電子病歷的基本架構(gòu)...............................................................................4
1.5 電子病歷的信息來源...............................................................................8
1.6 依據(jù)規(guī)范.................................................................................................11
1.7 建設(shè)原則.................................................................................................12
1.7.1 需求驅(qū)動 .........................................................................................12
1.7.2 分步實(shí)施 .........................................................................................13
1.7.3 規(guī)范標(biāo)準(zhǔn) .........................................................................................13
1.7.4 開放共享 .........................................................................................13
1.7.5 靈活實(shí)用 .........................................................................................13
1.7.6 安全可靠 .........................................................................................14
1.8 技術(shù)要求.................................................................................................14
1.8.1 數(shù)據(jù)標(biāo)準(zhǔn) .........................................................................................14
1.8.2 數(shù)據(jù)存儲 .........................................................................................14
1.8.3 信息安全 .........................................................................................15
1.8.4 接口要求 .........................................................................................15
1.8.5 運(yùn)行條件 .........................................................................................16
第 2 章應(yīng)用功能及系統(tǒng)概述 ............................................................17
2.1 基礎(chǔ)功能.................................................................................................17
2.1.1 用戶、權(quán)限管理 .............................................................................17
2.1.2 隱私保護(hù) .........................................................................................17
2.1.3 病歷模板管理 .................................................................................17
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
II
2.1.4 醫(yī)囑組套管理 .................................................................................17
2.1.5 醫(yī)學(xué)術(shù)語字典管理 .........................................................................18
2.1.6 日志及審計(jì) .....................................................................................18
2.1.7 數(shù)據(jù)質(zhì)量審核控制 .........................................................................18
2.1.8 數(shù)據(jù)存儲與管理 .............................................................................18
2.1.9 系統(tǒng)配置、維護(hù) .............................................................................18
2.1.10 電子病歷的接口 ...........................................................................18
2.2 主要功能.................................................................................................18
2.2.1 電子病歷創(chuàng)建 .................................................................................18
2.2.2 就診主索引創(chuàng)建 .............................................................................19
2.2.3 既往病史信息管理 .........................................................................19
2.2.4 門急診病歷管理 .............................................................................19
2.2.5 門診醫(yī)囑管理 .................................................................................19
2.2.6 住院病歷管理 .................................................................................19
2.2.7 住院醫(yī)囑管理 .................................................................................20
2.2.8 檢驗(yàn)檢查報(bào)告管理 .........................................................................20
2.2.9 轉(zhuǎn)診管理 .........................................................................................20
2.2.10 醫(yī)學(xué)證明及報(bào)告管理 ...................................................................20
2.2.11 健康體檢報(bào)告 ...............................................................................20
2.2.12 電子病歷查詢、輸出 ...................................................................20
2.2.13 其它信息查詢 ...............................................................................21
2.2.14 病案管理 .......................................................................................21
2.2.15 醫(yī)療統(tǒng)計(jì)分析 ...............................................................................21
2.2.16 醫(yī)療質(zhì)量、醫(yī)療行為、醫(yī)療安全管理 .......................................21
2.2.17 醫(yī)療知識支持 ...............................................................................22
2.2.18 醫(yī)保政策咨詢及醫(yī)囑規(guī)范警示 ...................................................23
2.3 擴(kuò)展功能.................................................................................................23
2.3.1 智能輔助診療決策 .........................................................................23
2.3.2 臨床路徑控制與管理 .....................................................................23
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
III
2.3.3 病歷結(jié)構(gòu)化處理 .............................................................................23
2.3.4 專病結(jié)構(gòu)化電子病歷 .....................................................................23
2.3.5 醫(yī)生移動應(yīng)用 .................................................................................23
2.3.6 護(hù)士移動應(yīng)用 .................................................................................23
2.3.7 病歷錄入的智能化控制 .................................................................23
2.3.8 區(qū)域臨床信息協(xié)同應(yīng)用 .................................................................24
2.3.9 基于循證醫(yī)學(xué)的病歷檢索、臨床研究 .........................................24
2.4 涉及的應(yīng)用系統(tǒng).....................................................................................24
2.4.1 基本應(yīng)用系統(tǒng) .................................................................................24
2.4.2 其它關(guān)聯(lián)臨床信息系統(tǒng) .................................................................25
第二篇功能篇........................................................................................26
第 3 章基礎(chǔ)功能 ................................................................................27
3.1 用戶與權(quán)限管理.....................................................................................27
3.1.1 基本要求 .........................................................................................27
3.1.2 推薦要求 .........................................................................................29
3.1.3 擴(kuò)展要求 .........................................................................................29
3.2 隱私保護(hù).................................................................................................29
3.2.1 基本要求 .........................................................................................29
3.2.2 推薦要求 .........................................................................................29
3.2.3 擴(kuò)展要求 .........................................................................................29
3.3 病歷模板管理.........................................................................................30
3.3.1 基本要求 .........................................................................................30
3.3.2 推薦要求 .........................................................................................30
3.3.3 擴(kuò)展要求 .........................................................................................30
3.4 醫(yī)囑組套管理.........................................................................................30
3.4.1 基本要求 .........................................................................................30
3.4.2 推薦要求 .........................................................................................31
3.4.3 擴(kuò)展要求 .........................................................................................31
3.5 醫(yī)學(xué)術(shù)語字典管理.................................................................................31
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
IV
3.5.1 基本要求 .........................................................................................31
3.5.2 推薦要求 .........................................................................................31
3.5.3 擴(kuò)展要求 .........................................................................................32
3.6 日志及審計(jì).............................................................................................32
3.6.1 基本要求 .........................................................................................32
3.6.2 推薦要求 .........................................................................................32
3.6.3 擴(kuò)展要求 .........................................................................................32
3.7 數(shù)據(jù)質(zhì)量審核控制.................................................................................33
3.7.1 基本要求 .........................................................................................33
3.7.2 推薦要求 .........................................................................................33
3.7.3 擴(kuò)展要求 .........................................................................................34
3.8 數(shù)據(jù)存儲與管理.....................................................................................34
3.8.1 基本要求 .........................................................................................34
3.8.2 推薦要求 .........................................................................................35
3.8.3 擴(kuò)展要求 .........................................................................................35
3.9 系統(tǒng)配置、維護(hù).....................................................................................35
3.9.1 基本要求 .........................................................................................35
3.9.2 推薦要求 .........................................................................................36
3.9.3 擴(kuò)展要求 .........................................................................................36
3.10 電子病歷應(yīng)用系統(tǒng)接口.........................................................................36
3.10.1 基本要求 .......................................................................................36
3.10.2 推薦要求 .......................................................................................37
3.10.3 擴(kuò)展要求 .......................................................................................37
第 4 章主要功能 ................................................................................39
4.1 電子病歷創(chuàng)建.........................................................................................39
4.1.1 基本要求 .........................................................................................39
4.1.2 推薦要求 .........................................................................................40
4.1.3 擴(kuò)展要求 .........................................................................................40
4.2 就診主索引創(chuàng)建.....................................................................................40
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
V
4.2.1 基本要求 .........................................................................................40
4.2.2 推薦要求 .........................................................................................41
4.2.3 擴(kuò)展要求 .........................................................................................41
4.3 既往病史信息管理.................................................................................41
4.3.1 基本要求 .........................................................................................41
4.3.2 推薦要求 .........................................................................................41
4.3.3 擴(kuò)展要求 .........................................................................................42
4.4 門急診病歷管理.....................................................................................42
4.4.1 基本要求 .........................................................................................42
4.4.2 推薦要求 .........................................................................................43
4.4.3 擴(kuò)展要求 .........................................................................................43
4.5 門診醫(yī)囑管理.........................................................................................44
4.5.1 基本要求 .........................................................................................44
4.5.2 推薦要求 .........................................................................................44
4.5.3 擴(kuò)展要求 .........................................................................................44
4.6 住院病歷管理.........................................................................................45
4.6.1 基本要求 .........................................................................................45
4.6.2 推薦要求 .........................................................................................47
4.6.3 擴(kuò)展要求 .........................................................................................48
4.7 住院醫(yī)囑管理.........................................................................................48
4.7.1 基本要求 .........................................................................................48
4.7.2 推薦要求 .........................................................................................50
4.7.3 擴(kuò)展要求 .........................................................................................51
4.8 檢驗(yàn)檢查報(bào)告管理.................................................................................51
4.8.1 基本要求 .........................................................................................51
4.8.2 推薦要求 .........................................................................................52
4.8.3 擴(kuò)展要求 .........................................................................................52
4.9 轉(zhuǎn)診管理.................................................................................................52
4.9.1 基本要求 .........................................................................................52
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
VI
4.9.2 推薦要求 .........................................................................................52
4.9.3 擴(kuò)展要求 .........................................................................................52
4.10 醫(yī)學(xué)證明及報(bào)告管理.............................................................................53
4.10.1 基本要求 .......................................................................................53
4.10.2 推薦要求 .......................................................................................53
4.10.3 擴(kuò)展要求 .......................................................................................53
4.11 健康體檢報(bào)告.........................................................................................53
4.11.1 基本要求 .......................................................................................53
4.11.2 推薦要求 .......................................................................................53
4.11.3 擴(kuò)展要求 .......................................................................................54
4.12 電子病歷查詢、輸出.............................................................................54
4.12.1 基本要求 .......................................................................................54
4.12.2 推薦要求 .......................................................................................55
4.12.3 擴(kuò)展要求 .......................................................................................55
4.13 其它信息查詢.........................................................................................56
4.13.1 基本要求 .......................................................................................56
4.13.2 推薦要求 .......................................................................................56
4.13.3 擴(kuò)展要求 .......................................................................................56
4.14 病案管理.................................................................................................56
4.14.1 基本要求 .......................................................................................56
4.14.2 推薦要求 .......................................................................................56
4.14.3 擴(kuò)展要求 .......................................................................................57
4.15 醫(yī)療統(tǒng)計(jì)分析.........................................................................................57
4.15.1 基本要求 .......................................................................................57
4.15.2 推薦要求 .......................................................................................57
4.15.3 擴(kuò)展要求 .......................................................................................57
4.16 醫(yī)療質(zhì)量、醫(yī)療行為、醫(yī)療安全管理.................................................58
4.16.1 基本要求 .......................................................................................58
4.16.2 推薦要求 .......................................................................................63
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
VII
4.16.3 擴(kuò)展要求 .......................................................................................63
4.17 醫(yī)療知識支持.........................................................................................64
4.17.1 基本要求 .......................................................................................64
4.17.2 推薦要求 .......................................................................................64
4.17.3 擴(kuò)展要求 .......................................................................................64
4.18 醫(yī)保政策咨詢及醫(yī)囑規(guī)范提醒.............................................................64
4.18.1 基本要求 .......................................................................................64
4.18.2 推薦要求 .......................................................................................65
4.18.3 擴(kuò)展要求 .......................................................................................65
第 5 章擴(kuò)展功能 ................................................................................66
5.1 智能輔助診療決策.................................................................................66
5.2 臨床路徑控制與管理.............................................................................66
5.3 病歷結(jié)構(gòu)化處理.....................................................................................67
5.4 專病結(jié)構(gòu)化電子病歷.............................................................................67
5.5 醫(yī)生移動應(yīng)用.........................................................................................67
5.6 護(hù)士移動應(yīng)用.........................................................................................68
5.7 病歷錄入的智能化控制.........................................................................69
5.8 區(qū)域臨床信息協(xié)同應(yīng)用.........................................................................69
5.9 基于循證醫(yī)學(xué)的病歷檢索、臨床研究.................................................69
第三篇應(yīng)用篇........................................................................................71
第 6 章門急診醫(yī)生工作站 ................................................................72
6.1 定義.........................................................................................................72
6.2 目標(biāo).........................................................................................................72
6.3 處理流程.................................................................................................72
6.4 功能描述.................................................................................................72
6.4.1 業(yè)務(wù)處理功能 .................................................................................73
6.4.2 信息利用功能 .................................................................................78
6.4.3 管理控制功能 .................................................................................79
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
VIII
6.5 接口要求.................................................................................................79
6.6 其它要求.................................................................................................80
第 7 章門急診護(hù)士工作站 ................................................................81
7.1 定義.........................................................................................................81
7.2 目標(biāo).........................................................................................................81
7.3 處理流程.................................................................................................81
7.4 功能描述.................................................................................................81
7.4.1 業(yè)務(wù)處理功能 .................................................................................81
7.4.2 信息利用功能 .................................................................................85
7.4.3 管理控制功能 .................................................................................85
7.5 接口要求.................................................................................................86
7.6 其它要求.................................................................................................86
第 8 章住院醫(yī)生工作站 ....................................................................87
8.1 定義.........................................................................................................87
8.2 目標(biāo).........................................................................................................87
8.3 處理流程.................................................................................................87
8.4 功能描述.................................................................................................88
8.4.1 業(yè)務(wù)處理功能 .................................................................................88
8.4.2 信息利用功能 .................................................................................91
8.4.3 管理控制功能 .................................................................................91
8.4.4 知識庫功能 .....................................................................................92
8.5 其他要求.................................................................................................92
第 9 章住院護(hù)士工作站 ....................................................................94
9.1 定義.........................................................................................................94
9.2 目標(biāo).........................................................................................................94
9.3 處理流程.................................................................................................94
9.4 功能描述.................................................................................................95
9.4.1 業(yè)務(wù)處理功能 .................................................................................95
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
IX
9.4.2 信息利用功能 .................................................................................97
9.4.3 管理控制功能 .................................................................................99
9.4.4 知識庫功能 ...................................................................................100
9.5 其他要求...............................................................................................101
第 10 章醫(yī)療質(zhì)量監(jiān)管系統(tǒng) ..............................................................102
10.1 定義.......................................................................................................102
10.2 目標(biāo).......................................................................................................102
10.3 處理流程...............................................................................................102
10.4 功能描述...............................................................................................103
10.4.1 業(yè)務(wù)處理功能 .............................................................................103
10.4.2 信息利用功能 .............................................................................105
10.4.3 管理控制功能 .............................................................................105
10.5 主要輸入輸出.......................................................................................105
10.5.1 輸入 .............................................................................................105
10.5.2 輸出 .............................................................................................106
10.6 其他要求...............................................................................................107
第 11 章電子病歷應(yīng)用配置管理系統(tǒng) ..............................................108
11.1 定義.......................................................................................................108
11.2 目標(biāo).......................................................................................................108
11.3 處理流程...............................................................................................108
11.4 功能描述...............................................................................................109
11.4.1 配置及運(yùn)維操作功能 .................................................................109
11.4.2 管理控制功能 ............................................................................. 111
11.4.3 信息利用功能 ............................................................................. 111
11.5 主要輸入輸出....................................................................................... 111
11.5.1 輸入 ............................................................................................. 111
11.5.2 輸出 .............................................................................................112
11.6 其它要求...............................................................................................112
第 12 章移動醫(yī)療系統(tǒng) ......................................................................113
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
X
12.1 定義.......................................................................................................113
12.2 目標(biāo).......................................................................................................113
12.3 處理流程...............................................................................................113
12.3.1 醫(yī)生處理流程 ...............................................................................114
12.3.2 護(hù)士處理流程 ...............................................................................115
12.4 功能描述...............................................................................................115
12.4.1 醫(yī)生業(yè)務(wù)處理 ...............................................................................115
12.4.2 護(hù)士業(yè)務(wù)處理 ...............................................................................117
12.5 其它要求...............................................................................................119
12.5.1 重要說明 .......................................................................................119
12.5.2 接口需求 .......................................................................................119
第 13 章電子認(rèn)證應(yīng)用 ......................................................................120
13.1 定義與目標(biāo)...........................................................................................120
13.1.1 定義 .............................................................................................120
13.1.2 目標(biāo) .............................................................................................120
13.2 應(yīng)用與服務(wù)模式...................................................................................120
13.2.1 電子認(rèn)證服務(wù) .............................................................................120
13.2.2 證書介質(zhì) .....................................................................................121
13.2.3 電子認(rèn)證過程 .............................................................................121
13.2.4 數(shù)字證書互認(rèn) .............................................................................121
13.3 處理流程...............................................................................................121
13.4 功能描述...............................................................................................122
13.4.1 業(yè)務(wù)處理功能 .............................................................................122
13.4.2 控制與維護(hù)功能 .........................................................................125
13.5 應(yīng)用范圍...............................................................................................127
13.6 其它要求...............................................................................................128
13.6.1 高內(nèi)聚低耦合的接口原則 .........................................................128
13.6.2 嵌入式應(yīng)用 .................................................................................128
13.6.3 與醫(yī)院信息系統(tǒng)過程融合 .........................................................128
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
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13.6.4 證書介質(zhì) .....................................................................................128
13.7 主要輸入輸出.......................................................................................129
13.7.1 輸入 .............................................................................................129
13.7.2 輸出 .............................................................................................129
第 14 章其它關(guān)聯(lián)臨床信息系統(tǒng) ......................................................130
14.1 定義與目標(biāo)...........................................................................................130
14.1.1 定義 .............................................................................................130
14.1.2 目標(biāo) .............................................................................................130
14.2 處理流程...............................................................................................131
14.3 電子病歷信息交互共享要求...............................................................132
14.3.1 檢驗(yàn)信息系統(tǒng)(LIS) ...................................................................132
14.3.2 檢查報(bào)告系統(tǒng)(RIS) ...................................................................133
14.3.3 醫(yī)學(xué)影像系統(tǒng)(PACS) .................................................................134
14.3.4 手術(shù)麻醉系統(tǒng) .............................................................................135
14.3.5 重癥監(jiān)護(hù)工作站 .........................................................................136
14.3.6 體檢信息系統(tǒng) .............................................................................137
14.3.7 用血管理系統(tǒng) .............................................................................137
14.3.8 營養(yǎng)配餐管理系統(tǒng) .....................................................................138
14.3.9 病案管理管理系統(tǒng) .....................................................................138
14.3.10 臨床路徑管理系統(tǒng) ...................................................................139
14.3.11 智能輔助診療決策系統(tǒng) ...........................................................140
14.3.12 醫(yī)學(xué)統(tǒng)計(jì)分析系統(tǒng) ...................................................................140
14.4 其它要求...............................................................................................141
14.4.1 數(shù)據(jù)存儲 .....................................................................................141
14.4.2 流程協(xié)同 .....................................................................................141
14.4.3 接口標(biāo)準(zhǔn) .....................................................................................141
14.4.4 功能規(guī)范 .....................................................................................141
14.5 主要輸入輸出.......................................................................................141
14.5.1 輸入 .............................................................................................142
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
XII
14.5.2 輸出 .............................................................................................142
第 15 章附則 ......................................................................................143
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
1
第一篇概論篇
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
2
前言
本實(shí)施細(xì)則由上海市衛(wèi)生局醫(yī)政處、信息中心組織人員編寫。
本實(shí)施細(xì)則根據(jù)衛(wèi)生部《電子病歷系統(tǒng)功能規(guī)范（試行）》、《上海市電子
病歷試點(diǎn)工作方案》，以上海市醫(yī)療機(jī)構(gòu)電子病歷應(yīng)用的實(shí)際情況為基礎(chǔ)，適
用于上海市各級醫(yī)療機(jī)構(gòu)的電子病歷應(yīng)用系統(tǒng)的建設(shè)、應(yīng)用及評估。
本實(shí)施細(xì)則分為概論篇、功能篇、應(yīng)用篇三個(gè)部分。
概論篇描述了電子病歷的概念、應(yīng)用目的、目標(biāo)、基本架構(gòu)、信息來源、
依據(jù)規(guī)范、建設(shè)原則、技術(shù)要求，是對各級醫(yī)療機(jī)構(gòu)建設(shè)電子病歷的總體要求。
概論篇還簡要介紹了電子病歷應(yīng)用功能及涉及的應(yīng)用系統(tǒng)。
功能篇主要描述了電子病歷應(yīng)用所涉及的功能類型、內(nèi)容以及用法。電子
病歷的應(yīng)用功能按照功能屬性、應(yīng)用深度、實(shí)現(xiàn)難易程度，劃分為基礎(chǔ)功能、
主要功能、擴(kuò)展功能，基礎(chǔ)功能、主要功能是實(shí)施電子病歷應(yīng)用的必備功能，
擴(kuò)展功能是電子病歷應(yīng)用的可選功能。功能篇按上述分類對電子病歷所涉及的
應(yīng)用功能進(jìn)行具體描述，并將功能區(qū)分為基本要求、推薦要求、擴(kuò)展要求三個(gè)
應(yīng)用級別，以便指導(dǎo)用戶合理建設(shè)、應(yīng)用。
應(yīng)用篇按照與電子病歷的相關(guān)性將應(yīng)用系統(tǒng)分類為主要應(yīng)用系統(tǒng)、擴(kuò)展應(yīng)
用系統(tǒng)、其它關(guān)聯(lián)臨床信息系統(tǒng)，把具體功能按臨床業(yè)務(wù)流程和需求進(jìn)行串聯(lián)
描述，是對功能篇中描述的應(yīng)用功能的具體實(shí)現(xiàn)，用于指導(dǎo)各級醫(yī)療機(jī)構(gòu)建立
以電子病歷為核心的臨床應(yīng)用系統(tǒng)。
本實(shí)施細(xì)則撰寫過程中得到了市衛(wèi)生局醫(yī)政處、病案質(zhì)量管理中心、醫(yī)療
機(jī)構(gòu)、開發(fā)商等各方面專家的幫助和指導(dǎo)，在此一并表示衷心感謝！
主要撰寫人員：范啟勇，劉青，曹劍鋒，袁駿毅、陳亦云、況華、黃
新霆等
上海市電子病歷應(yīng)用功能規(guī)范實(shí)施細(xì)則
3
第1章電子病歷應(yīng)用的總體要求
1.1 電子病歷的基本概念
電子病歷是醫(yī)療機(jī)構(gòu)對門急診、住院、健康體檢患者（或保健對象）臨床
診療和指導(dǎo)干預(yù)的、數(shù)字化的醫(yī)療服務(wù)工作記錄。是居民個(gè)人在醫(yī)療機(jī)構(gòu)歷次
就診過程中產(chǎn)生和被記錄的完整、詳細(xì)的臨床信息資源。
電子病歷應(yīng)用與醫(yī)院信息系統(tǒng)有著密切關(guān)系，一份完整電子病歷的生成依
賴醫(yī)院各個(gè)業(yè)務(wù)信息子系統(tǒng)的有機(jī)整合，因此實(shí)現(xiàn)電子病歷應(yīng)用首先就要實(shí)現(xiàn)
醫(yī)療過程的信息化。

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