医学信息
醫學信息
의학신식
MEDICAL INFORMATION
2014年
7期
180-181
,共2页
李亚玲%李明%毕珍%赵越%张瑜珊
李亞玲%李明%畢珍%趙越%張瑜珊
리아령%리명%필진%조월%장유산
电子病历书写质量%缺陷分析与对策%病案管理质量
電子病歷書寫質量%缺陷分析與對策%病案管理質量
전자병역서사질량%결함분석여대책%병안관리질량
Electronic medical record writing quality%Defects analysis and Countermeasures%The quality of medical record management
目的：规避电子病历记录存在缺陷，确保病案信息的法律依据的客观性、真实性，确保医疗质量，杜绝医疗纠纷。方法统计分析我院2012年7~12月948份电子病历应用存在的缺陷。结果948份电子病历中有596份存在记录缺陷，缺陷率62.87%，主要为入院记录、病程记录、出院记录、医嘱单和病案首页记录缺陷。结论加强电子病历质量监控，是医院实施全面质量管理的关键环节，是一项不可以忽视的重要工作。
目的：規避電子病歷記錄存在缺陷，確保病案信息的法律依據的客觀性、真實性，確保醫療質量，杜絕醫療糾紛。方法統計分析我院2012年7~12月948份電子病歷應用存在的缺陷。結果948份電子病歷中有596份存在記錄缺陷，缺陷率62.87%，主要為入院記錄、病程記錄、齣院記錄、醫囑單和病案首頁記錄缺陷。結論加彊電子病歷質量鑑控，是醫院實施全麵質量管理的關鍵環節，是一項不可以忽視的重要工作。
목적：규피전자병력기록존재결함，학보병안신식적법률의거적객관성、진실성，학보의료질량，두절의료규분。방법통계분석아원2012년7~12월948빈전자병력응용존재적결함。결과948빈전자병력중유596빈존재기록결함，결함솔62.87%，주요위입원기록、병정기록、출원기록、의촉단화병안수혈기록결함。결론가강전자병력질량감공，시의원실시전면질량관리적관건배절，시일항불가이홀시적중요공작。
Objective to avoid the defects of electronic records, ensure objectivity, the legal basis for the medical record information authenticity, ensure the medical quality, to prevent medical disputes. Method Analysis of our hospital in 2012 7-12 month 948 in application of electronic medical record defect statistics. Results of the 948 electronic medical records of 596 existing record defects, defect rate of 62.87%, mainly for the admission records, records, hospital records, doctor's advice and medical record record defects. Conclusion to strengthen quality control is the key link of hospital electronic medical records, the implementation of total quality management, is an important work can not be ignored.
