目的：病歷電子化已為必然趨勢，但台灣放射腫瘤專科的病歷系統大多獨立於醫院資訊系統 （hospital information system, HIS）之外，或與醫院資訊系統未同步連結，存在癌病團隊成員不 易取得本專科資訊等問題。因此，本研究目的為建立與 HIS 系統及放腫癌登資料庫整合的放腫專 科各項病歷的電子病歷系統，兼顧資訊的正確性、效率性、安全性、即時性。 材料與方法：確定各項專科病歷資訊需求、科內作業流程、及舊有癌登作業功能，在 Java 2 Enterprise Edition 架構運用 JAVA 與 WEB 網頁技術，開發放射腫瘤科電子病歷系統。考量放腫 科治療病歷各欄位實際儲存的特性、未來統計分析需求，將資料定義成不同格式保存。並以反向 工程（Reverse engineering）概念，將原有單機版癌登作業重新建罝為與本院醫療系統整合之 web 版，資料亦匯入並轉換相容於新系統中，以達到線上整合操作與即時查詢的目標。 結果：完成各項放腫電子病歷包括有：初始病歷、病程紀錄副作用表、近接治療紀錄、放射治療 摘要紀錄及放腫癌登資料庫。與 HIS 整合及資料共享，可大幅減少臨床醫師書寫病歷時間與重複 輸入造成的錯誤，並強化對其他癌症團隊成員的資訊即時性與透明性。 結論：本研究設計的放腫電子病歷系統，除可減少專科病歷書寫時間，亦可建立包含完整病史及 其他癌病資訊的資料庫以供未來研究使用；因應未來病歷政策的改變也更具彈性。

Purpose : Electronic medical records (EMR) have become indispensable. However, most medical records systems for radiation oncology in Taiwan are independent from hospital information systems (HIS), or asynchronous with HIS. It is difficult to gather information on radiation oncology for other members of cancer treatment team. Therefore, the aim of this study is to build an EMR system, which integrates with both HIS and the cancer registry database, to achieve efficient, safe, instant transfer of information. Materials & Methods : The needs of radiation oncology medical records, the existing processes, and the functions of the cancer registry system were identified first. By applying Java and web technology under J2EE architecture, we developed an electronic medical records system. Considering the characteristics of information storage and the need for future statistical analysis, we defined the information in the notes as different forms. We built a web-based version of the cancer registry system integrated with HIS, using the concept of reverse engineering. The data from the previous cancer registry system was imported and converted to be compatible with the new system to achieve the goal of online operation and real-time search. Results : The electronic medical records system included initial notes, acute radiation morbidity records, brachytherapy notes, complete notes, and a cancer registry database. By integrating with the HIS and sharing the information, we can reduce the time and possible mistakes clinicians spend on medical records and repeated inputing. The instant transparency for other members of the cancer treatment team are improved by the system as well. Conclusions : The electronic medical records designed by this study not only reduce documentation time, but also build a database containing complete patient history and other cancer information for retrospective study or clinical trial. It is also more flexible in response to changes in medical records policy.