与电子病历相关的缩写和术语
Abbreviations and Terms Related to Electronic Medical Records
美国的法规支持在所有医疗保健机构和医生办公室实施电子病历系统。
U.S. regulations support the implementation of Electronic Medical Records systems in all health care facilities and physicians' offices.
电子病历设有密码保护，目的是保护医疗信息的保密性。
Electronic Medical Records are password-protected with the aim of protecting confidentiality of medical information.
电子病历（EMR）是指在一个机构或医疗保健系统内的电子临床记录系统。
Electronic Medical Record (EMR) is a system of electronic clinical documentation within an institution or health care system.
它是一个机构或医疗保健系统中患者纸质“病历”的数字化版本。
It is a digital version of a patient's paper "chart" for an institution or health care system.
缩写：EMR
Abbreviation: EMR
示例
Example
查看一份电子病历中生命体征部分的示例。
View an example of the vital signs portion of an EMR.
根据你先前的知识，尝试回答以下问题：
Based on your prior knowledge, try to answer the following questions:
心率是多少（每分钟心跳次数，BPM）？
What is the heart's BPM?
呼吸频率（每分钟呼吸次数，RPM）是多少？
What is the RPM?
血氧饱和度（SpO2）情况如何？
How is the SpO2?
你认识“心尖（apical）”这个单词吗？
Do you recognize the word apical?
注意4个小时内血压（BP）的变化。
Note the difference in BP over 4 hours.
写下你的描述。
Write down your description.
这正常吗？
Is this normal?
这位患者的生命体征正常吗？
Are this patient's vitals normal?
电子健康档案（EHR），这一术语有时可与电子病历（EMR）互换使用。
Electronic Health Record or EHR is a term sometimes used interchangeably with EMR.
其定义在不断演变且存在差异。
Definitions are evolving and vary.
新入行的从业者最有可能使用电子病历（EMR），它是以前患者纸质病历的数字化形式。
The new practitioner is most likely to use the EMR, a digital form of what was previously the patient’s chart.
电子健康档案（EHR）是来自不同来源（实验室、不同医疗系统的医疗服务提供者等）的记录集合，它反映了患者更广泛的健康状况。
The EHR is a collection of records from sources (labs, providers from different health systems, etc.) and reflects the broader scope of the patient’s health.
电子病历（EMR）可供医院内的医疗服务提供者访问（例如，放射科技术人员需要知道患者上次服药的时间），也可供医院外的人员访问，如紧急医疗服务人员或社区医生。
The EMR can be accessed by health care providers in the hospital (For example, a radiology technician needs to know when a patient had his last dose of a medication.) or by those outside of the hospital such as emergency medical services or community practitioners.
药物管理
Administering Medications
1) 电子药物管理记录
1) Electronic Medication Administration Record
借助技术手段和条形码，电子药物管理记录（eMAR）方便了药物的处方开具、药房配药以及护士给药。
Using technology and bar coding, the Electronic Medication Administration Record or eMAR facilitates the prescribing of medications, dispensing by the pharmacy, and administration by the nurse.
药房以电子方式接收医生的医嘱，然后准备药物并附上条形码。
The pharmacy electronically receives the physician’s order, and the drug is prepared and barcoded.
给药的护士会检查药物条形码与患者身份识别手环上的条形码是否匹配，同时会询问患者的姓名。
The nurse administering the medication checks for barcode match with the patient’s ID bracelet as well as eliciting the patient’s name.
使用电子药物管理记录（eMAR）有助于确保给正确的患者使用正确的药物。
Using the eMar helps to ensure that the right medication is given to the right patient.
药物信息、给药时间和给药人员的身份信息会自动记录在电子健康档案（EHR）中。
The medication, time and administrator’s identification are automatically recorded in the EHR.
缩写：eMAR
Abbreviation: eMAR
示例
Example
查看一份电子药物管理记录（eMAR）的示例。
View an example of an eMAR.
你可能会注意到有关药物剂量和给药时间的信息，以及特定药物名称的缩写。
You may notice information about medication dosing and timing, as well as abbreviations for the names of specific medications.
2) 药车
2) Medication Cart
患者的药物通常存放在一个可移动的工作站上，并通过该工作站进行运送，这个工作站可以从一个房间推到另一个房间。
Patient medications are typically maintained and transported on a work station that can be moved from room to room.
药车是一种便携式工作站，里面装有一台计算机、患者的药物以及相关用品。
A Medication Cart is a portable work station containing a computer, patient medications, and supplies.
缩写：Med cart
Abbreviation: Med cart