财米财米
电子病历的英文缩写为EMR。
电子病历（EMR,Electronic Medical Record），也叫计算机化的病案系统或称基于计算机的病人记录（CPR,Computer-Based Patient Record）。
它是用电子设备（计算机、健康卡等）保存、管理、传输和重现的数字化的病人的医疗记录，取代手写纸张病历。它的内容包括纸张病历的所有信息。
美国国立医学研究所将定义为：EMR是基于一个特定系统的电子化病人记录， 该系统提供用户访问完整准确的数据、警示、提示和临床决策支持系统的能力。
病历是病人在医院诊断治疗全过程的原始记录，它包含有首页、病程记录、检查检验结果、医嘱、手术记录、护理记录等等。电子病历不仅指静态病历信息，还包括提供的相关服务。
是以电子化方式管理的有关个人终生健康状态和医疗保健行为的信息，涉及病人信息的采集、存储、传输、处理和利用的所有过程信息。
电子病历是随着医院计算机管理网络化、信息存储介质--光盘和IC 卡等的应用及Internet的全球化而产生的。
电子病历是信息技术和网络技术在医疗领域的必然产物，是医院病历现代化管理的必然趋势，其在临床的初步应用，极大地提高了医院的工作效率和医疗质量，但这还仅仅是电子病历应用的起步。
Yoyo030303
病历 [词典] （病案； 病史） medical record; case history; [例句]结果将记入你的病历。The result will go on your medical records.
sizonghang
A Sample of Complete History PATIENT'S NAME: Mary Swan CHART NUMBER: 660518 DATE OF BIRTH:10-5-1993 SEX: Female DATE OF ADMISSION: 10-12-2000 DATE OF DISCHARGE: 10-15-2000 Final Discharge Summary Chief Complaint: Coughing, wheezing with difficult respirations. Present Illness: This is the first John Hopkins Hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to Tedral or cough medicine. The wheezing progressed and the child was taken to John Hopkins Hospital Emergency Room where the child was given epinephrine and oxygen. She was sent home. The patient was brought back to the ER three hours later was admitted. Past History: The child was a product of an 8.5-month gestation. The mother had toxemia of pregnancy. Immunizations: All. Feeding: Good. Allergies: Chocolate, dog hair, tomatoes. Family History: The mother is 37, alive and well. The father is 45, alive and well. Two sibs, one brother and one sister, alive and well. The family was not positive for asthma, diabetes, etc. Review of Systems: Negative except for occasional conjunctivitis and asthma. Physical Examination on Admission: The physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and temperature of 101.0℉. She was in a mist tent at the time of examination. Funduscopic examination revealed normal fundi with flat discs. Nose and throat were somewhat injected, particularly the posterior pharynx. The carotids were palpable and equal. Ears were clear. Thyroid not palpable. The examination of the chest revealed bilateral inspiratory and expiratory wheezes. Breath sounds were decreased in the left anterior lung field. The heart was normal. Abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. The bowel sounds were normal. Pelvic: Normal female child. Rectal deferred. Extremities negative. Impression: Bronchial asthma, and pharyngitis. Laboratory Data: The white count on admission was 13,600 with hgb of 13.0. Differential revealed 64 segs and 35 lymphs with 3 Eos. Adequate platelets. Sputum culture and sensitivity revealed Alpha hemolytic streptococcus sensitive to Penicillin. Chest x-ray on admission showed hyperaeration and prominent bronchovascular markings. The child was started on procaine Penicillin 600,000 unites IM q.d in accordance with the culture and sensitivity of the sputum. Hospital Course: The child was given Penicillin IM as stated above. Ten drops of Isuprel were added to the respirator every 2 hours. The patient improved steadily. She took her diet well. She was discharged on 10-15-2000 in good condition. Operation procedure: none Condition on discharge: Improved Diagnosis: Asthma. Pharyngitis. Possible right upper lobs pneumonia.
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