上海市衛生局
2011 年10 月
上海市電子病歷應用功能規范實施細則
I
目錄
第一篇 概論篇..........................................................................................1
前言.............................................................................................................2
第 1 章 電子病歷應用的總體要求 ......................................................3
1.1 電子病歷的基本概念...............................................................................3
1.2 電子病歷的應用目的...............................................................................3
1.3 電子病歷的應用目標...............................................................................3
1.4 電子病歷的基本架構...............................................................................4
1.5 電子病歷的信息來源...............................................................................8
1.6 依據規范.................................................................................................11
1.7 建設原則.................................................................................................12
1.7.1 需求驅動 .........................................................................................12
1.7.2 分步實施 .........................................................................................13
1.7.3 規范標準 .........................................................................................13
1.7.4 開放共享 .........................................................................................13
1.7.5 靈活實用 .........................................................................................13
1.7.6 安全可靠 .........................................................................................14
1.8 技術要求.................................................................................................14
1.8.1 數據標準 .........................................................................................14
1.8.2 數據存儲 .........................................................................................14
1.8.3 信息安全 .........................................................................................15
1.8.4 接口要求 .........................................................................................15
1.8.5 運行條件 .........................................................................................16
第 2 章 應用功能及系統概述 ............................................................17
2.1 基礎功能.................................................................................................17
2.1.1 用戶、權限管理 .............................................................................17
2.1.2 隱私保護 .........................................................................................17
2.1.3 病歷模板管理 .................................................................................17
上海市電子病歷應用功能規范實施細則
II
2.1.4 醫囑組套管理 .................................................................................17
2.1.5 醫學術語字典管理 .........................................................................18
2.1.6 日志及審計 .....................................................................................18
2.1.7 數據質量審核控制 .........................................................................18
2.1.8 數據存儲與管理 .............................................................................18
2.1.9 系統配置、維護 .............................................................................18
2.1.10 電子病歷的接口 ...........................................................................18
2.2 主要功能.................................................................................................18
2.2.1 電子病歷創建 .................................................................................18
2.2.2 就診主索引創建 .............................................................................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 門診醫囑管理 .................................................................................19
2.2.6 住院病歷管理 .................................................................................19
2.2.7 住院醫囑管理 .................................................................................20
2.2.8 檢驗檢查報告管理 .........................................................................20
2.2.9 轉診管理 .........................................................................................20
2.2.10 醫學證明及報告管理 ...................................................................20
2.2.11 健康體檢報告 ...............................................................................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 醫療統計分析 ...............................................................................21
2.2.16 醫療質量、醫療行為、醫療安全管理 .......................................21
2.2.17 醫療知識支持 ...............................................................................22
2.2.18 醫保政策咨詢及醫囑規范警示 ...................................................23
2.3 擴展功能.................................................................................................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
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2.3.3 病歷結構化處理 .............................................................................23
2.3.4 專病結構化電子病歷 .....................................................................23
2.3.5 醫生移動應用 .................................................................................23
2.3.6 護士移動應用 .................................................................................23
2.3.7 病歷錄入的智能化控制 .................................................................23
2.3.8 區域臨床信息協同應用 .................................................................24
2.3.9 基于循證醫學的病歷檢索、臨床研究 .........................................24
2.4 涉及的應用系統.....................................................................................24
2.4.1 基本應用系統 .................................................................................24
2.4.2 其它關聯臨床信息系統 .................................................................25
第二篇 功能篇........................................................................................26
第 3 章 基礎功能 ................................................................................27
3.1 用戶與權限管理.....................................................................................27
3.1.1 基本要求 .........................................................................................27
3.1.2 推薦要求 .........................................................................................29
3.1.3 擴展要求 .........................................................................................29
3.2 隱私保護.................................................................................................29
3.2.1 基本要求 .........................................................................................29
3.2.2 推薦要求 .........................................................................................29
3.2.3 擴展要求 .........................................................................................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 擴展要求 .........................................................................................30
3.4 醫囑組套管理.........................................................................................30
3.4.1 基本要求 .........................................................................................30
3.4.2 推薦要求 .........................................................................................31
3.4.3 擴展要求 .........................................................................................31
3.5 醫學術語字典管理.................................................................................31
上海市電子病歷應用功能規范實施細則
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3.5.1 基本要求 .........................................................................................31
3.5.2 推薦要求 .........................................................................................31
3.5.3 擴展要求 .........................................................................................32
3.6 日志及審計.............................................................................................32
3.6.1 基本要求 .........................................................................................32
3.6.2 推薦要求 .........................................................................................32
3.6.3 擴展要求 .........................................................................................32
3.7 數據質量審核控制.................................................................................33
3.7.1 基本要求 .........................................................................................33
3.7.2 推薦要求 .........................................................................................33
3.7.3 擴展要求 .........................................................................................34
3.8 數據存儲與管理.....................................................................................34
3.8.1 基本要求 .........................................................................................34
3.8.2 推薦要求 .........................................................................................35
3.8.3 擴展要求 .........................................................................................35
3.9 系統配置、維護.....................................................................................35
3.9.1 基本要求 .........................................................................................35
3.9.2 推薦要求 .........................................................................................36
3.9.3 擴展要求 .........................................................................................36
3.10 電子病歷應用系統接口.........................................................................36
3.10.1 基本要求 .......................................................................................36
3.10.2 推薦要求 .......................................................................................37
3.10.3 擴展要求 .......................................................................................37
第 4 章 主要功能 ................................................................................39
4.1 電子病歷創建.........................................................................................39
4.1.1 基本要求 .........................................................................................39
4.1.2 推薦要求 .........................................................................................40
4.1.3 擴展要求 .........................................................................................40
4.2 就診主索引創建.....................................................................................40
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4.2.1 基本要求 .........................................................................................40
4.2.2 推薦要求 .........................................................................................41
4.2.3 擴展要求 .........................................................................................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 擴展要求 .........................................................................................43
4.5 門診醫囑管理.........................................................................................44
4.5.1 基本要求 .........................................................................................44
4.5.2 推薦要求 .........................................................................................44
4.5.3 擴展要求 .........................................................................................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 擴展要求 .........................................................................................48
4.7 住院醫囑管理.........................................................................................48
4.7.1 基本要求 .........................................................................................48
4.7.2 推薦要求 .........................................................................................50
4.7.3 擴展要求 .........................................................................................51
4.8 檢驗檢查報告管理.................................................................................51
4.8.1 基本要求 .........................................................................................51
4.8.2 推薦要求 .........................................................................................52
4.8.3 擴展要求 .........................................................................................52
4.9 轉診管理.................................................................................................52
4.9.1 基本要求 .........................................................................................52
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4.9.2 推薦要求 .........................................................................................52
4.9.3 擴展要求 .........................................................................................52
4.10 醫學證明及報告管理.............................................................................53
4.10.1 基本要求 .......................................................................................53
4.10.2 推薦要求 .......................................................................................53
4.10.3 擴展要求 .......................................................................................53
4.11 健康體檢報告.........................................................................................53
4.11.1 基本要求 .......................................................................................53
4.11.2 推薦要求 .......................................................................................53
4.11.3 擴展要求 .......................................................................................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 擴展要求 .......................................................................................57
4.15 醫療統計分析.........................................................................................57
4.15.1 基本要求 .......................................................................................57
4.15.2 推薦要求 .......................................................................................57
4.15.3 擴展要求 .......................................................................................57
4.16 醫療質量、醫療行為、醫療安全管理.................................................58
4.16.1 基本要求 .......................................................................................58
4.16.2 推薦要求 .......................................................................................63
上海市電子病歷應用功能規范實施細則
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4.16.3 擴展要求 .......................................................................................63
4.17 醫療知識支持.........................................................................................64
4.17.1 基本要求 .......................................................................................64
4.17.2 推薦要求 .......................................................................................64
4.17.3 擴展要求 .......................................................................................64
4.18 醫保政策咨詢及醫囑規范提醒.............................................................64
4.18.1 基本要求 .......................................................................................64
4.18.2 推薦要求 .......................................................................................65
4.18.3 擴展要求 .......................................................................................65
第 5 章 擴展功能 ................................................................................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 病歷結構化處理.....................................................................................67
5.4 專病結構化電子病歷.............................................................................67
5.5 醫生移動應用.........................................................................................67
5.6 護士移動應用.........................................................................................68
5.7 病歷錄入的智能化控制.........................................................................69
5.8 區域臨床信息協同應用.........................................................................69
5.9 基于循證醫學的病歷檢索、臨床研究.................................................69
第三篇 應用篇........................................................................................71
第 6 章 門急診醫生工作站 ................................................................72
6.1 定義.........................................................................................................72
6.2 目標.........................................................................................................72
6.3 處理流程.................................................................................................72
6.4 功能描述.................................................................................................72
6.4.1 業務處理功能 .................................................................................73
6.4.2 信息利用功能 .................................................................................78
6.4.3 管理控制功能 .................................................................................79
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6.5 接口要求.................................................................................................79
6.6 其它要求.................................................................................................80
第 7 章 門急診護士工作站 ................................................................81
7.1 定義.........................................................................................................81
7.2 目標.........................................................................................................81
7.3 處理流程.................................................................................................81
7.4 功能描述.................................................................................................81
7.4.1 業務處理功能 .................................................................................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 住院醫生工作站 ....................................................................87
8.1 定義.........................................................................................................87
8.2 目標.........................................................................................................87
8.3 處理流程.................................................................................................87
8.4 功能描述.................................................................................................88
8.4.1 業務處理功能 .................................................................................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 住院護士工作站 ....................................................................94
9.1 定義.........................................................................................................94
9.2 目標.........................................................................................................94
9.3 處理流程.................................................................................................94
9.4 功能描述.................................................................................................95
9.4.1 業務處理功能 .................................................................................95
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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 章醫療質量監管系統 ..............................................................102
10.1 定義.......................................................................................................102
10.2 目標.......................................................................................................102
10.3 處理流程...............................................................................................102
10.4 功能描述...............................................................................................103
10.4.1 業務處理功能 .............................................................................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 章電子病歷應用配置管理系統 ..............................................108
11.1 定義.......................................................................................................108
11.2 目標.......................................................................................................108
11.3 處理流程...............................................................................................108
11.4 功能描述...............................................................................................109
11.4.1 配置及運維操作功能 .................................................................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 章移動醫療系統 ......................................................................113
上海市電子病歷應用功能規范實施細則
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12.1 定義.......................................................................................................113
12.2 目標.......................................................................................................113
12.3 處理流程...............................................................................................113
12.3.1 醫生處理流程 ...............................................................................114
12.3.2 護士處理流程 ...............................................................................115
12.4 功能描述...............................................................................................115
12.4.1 醫生業務處理 ...............................................................................115
12.4.2 護士業務處理 ...............................................................................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 章電子認證應用 ......................................................................120
13.1 定義與目標...........................................................................................120
13.1.1 定義 .............................................................................................120
13.1.2 目標 .............................................................................................120
13.2 應用與服務模式...................................................................................120
13.2.1 電子認證服務 .............................................................................120
13.2.2 證書介質 .....................................................................................121
13.2.3 電子認證過程 .............................................................................121
13.2.4 數字證書互認 .............................................................................121
13.3 處理流程...............................................................................................121
13.4 功能描述...............................................................................................122
13.4.1 業務處理功能 .............................................................................122
13.4.2 控制與維護功能 .........................................................................125
13.5 應用范圍...............................................................................................127
13.6 其它要求...............................................................................................128
13.6.1 高內聚低耦合的接口原則 .........................................................128
13.6.2 嵌入式應用 .................................................................................128
13.6.3 與醫院信息系統過程融合 .........................................................128
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13.6.4 證書介質 .....................................................................................128
13.7 主要輸入輸出.......................................................................................129
13.7.1 輸入 .............................................................................................129
13.7.2 輸出 .............................................................................................129
第 14 章其它關聯臨床信息系統 ......................................................130
14.1 定義與目標...........................................................................................130
14.1.1 定義 .............................................................................................130
14.1.2 目標 .............................................................................................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 檢驗信息系統(LIS) ...................................................................132
14.3.2 檢查報告系統(RIS) ...................................................................133
14.3.3 醫學影像系統(PACS) .................................................................134
14.3.4 手術麻醉系統 .............................................................................135
14.3.5 重癥監護工作站 .........................................................................136
14.3.6 體檢信息系統 .............................................................................137
14.3.7 用血管理系統 .............................................................................137
14.3.8 營養配餐管理系統 .....................................................................138
14.3.9 病案管理管理系統 .....................................................................138
14.3.10 臨床路徑管理系統 ...................................................................139
14.3.11 智能輔助診療決策系統 ...........................................................140
14.3.12 醫學統計分析系統 ...................................................................140
14.4 其它要求...............................................................................................141
14.4.1 數據存儲 .....................................................................................141
14.4.2 流程協同 .....................................................................................141
14.4.3 接口標準 .....................................................................................141
14.4.4 功能規范 .....................................................................................141
14.5 主要輸入輸出.......................................................................................141
14.5.1 輸入 .............................................................................................142
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14.5.2 輸出 .............................................................................................142
第 15 章附則 ......................................................................................143
上海市電子病歷應用功能規范實施細則
1
第一篇 概論篇
上海市電子病歷應用功能規范實施細則
2
前言
本實施細則由上海市衛生局醫政處、信息中心組織人員編寫。
本實施細則根據衛生部《電子病歷系統功能規范（試行）》、《上海市電子
病歷試點工作方案》，以上海市醫療機構電子病歷應用的實際情況為基礎，適
用于上海市各級醫療機構的電子病歷應用系統的建設、應用及評估。
本實施細則分為概論篇、功能篇、應用篇三個部分。
概論篇描述了電子病歷的概念、應用目的、目標、基本架構、信息來源、
依據規范、建設原則、技術要求，是對各級醫療機構建設電子病歷的總體要求。
概論篇還簡要介紹了電子病歷應用功能及涉及的應用系統。
功能篇主要描述了電子病歷應用所涉及的功能類型、內容以及用法。電子
病歷的應用功能按照功能屬性、應用深度、實現難易程度，劃分為基礎功能、
主要功能、擴展功能，基礎功能、主要功能是實施電子病歷應用的必備功能，
擴展功能是電子病歷應用的可選功能。功能篇按上述分類對電子病歷所涉及的
應用功能進行具體描述，并將功能區分為基本要求、推薦要求、擴展要求三個
應用級別，以便指導用戶合理建設、應用。
應用篇按照與電子病歷的相關性將應用系統分類為主要應用系統、擴展應
用系統、其它關聯臨床信息系統，把具體功能按臨床業務流程和需求進行串聯
描述，是對功能篇中描述的應用功能的具體實現，用于指導各級醫療機構建立
以電子病歷為核心的臨床應用系統。
本實施細則撰寫過程中得到了市衛生局醫政處、病案質量管理中心、醫療
機構、開發商等各方面專家的幫助和指導，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
上海市電子病歷應用功能規范實施細則
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第1章 電子病歷應用的總體要求
1.1 電子病歷的基本概念
電子病歷是醫療機構對門急診、住院、健康體檢患者（或保健對象）臨床
診療和指導干預的、數字化的醫療服務工作記錄。是居民個人在醫療機構歷次
就診過程中產生和被記錄的完整、詳細的臨床信息資源。
電子病歷應用與醫院信息系統有著密切關系，一份完整電子病歷的生成依
賴醫院各個業務信息子系統的有機整合，因此實現電子病歷應用首先就要實現
醫療過程的信息化。 |
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