办公自动化（学术版）
辦公自動化（學術版）
판공자동화（학술판）
Office Automation
2014年
6期
36-38
,共3页
电子病历%手写病历%模板粘贴%电子病历质控
電子病歷%手寫病歷%模闆粘貼%電子病歷質控
전자병력%수사병력%모판점첩%전자병력질공
Electronic medical records%Written medical records%Template pasted%Quality control of electronic medical records
目的：提高病历档案书写质量。方法：通过比较电子病历档案与传统手写病历档案的医疗文书质量的优劣，质量缺陷的出现情况。结果：电子病历档案的真实性缺陷多于手写病历档案，传统手写病历档案的及时性、完整性、规范性缺陷的出现率多于电子病历档案。结论：电子病历档案存在复制功能不规范使用、模板粘贴过分依赖、电子签名随意等问题。必须增强责任心，完善电子病历质控系统功能，加强电子病历系统功能应用管理，才能进一步改善电子病历质量。强化书写证据意识，从而保护医患双方的合法权益。
目的：提高病歷檔案書寫質量。方法：通過比較電子病歷檔案與傳統手寫病歷檔案的醫療文書質量的優劣，質量缺陷的齣現情況。結果：電子病歷檔案的真實性缺陷多于手寫病歷檔案，傳統手寫病歷檔案的及時性、完整性、規範性缺陷的齣現率多于電子病歷檔案。結論：電子病歷檔案存在複製功能不規範使用、模闆粘貼過分依賴、電子籤名隨意等問題。必鬚增彊責任心，完善電子病歷質控繫統功能，加彊電子病歷繫統功能應用管理，纔能進一步改善電子病歷質量。彊化書寫證據意識，從而保護醫患雙方的閤法權益。
목적：제고병력당안서사질량。방법：통과비교전자병력당안여전통수사병력당안적의료문서질량적우렬，질량결함적출현정황。결과：전자병력당안적진실성결함다우수사병력당안，전통수사병력당안적급시성、완정성、규범성결함적출현솔다우전자병력당안。결론：전자병력당안존재복제공능불규범사용、모판점첩과분의뢰、전자첨명수의등문제。필수증강책임심，완선전자병력질공계통공능，가강전자병력계통공능응용관리，재능진일보개선전자병력질량。강화서사증거의식，종이보호의환쌍방적합법권익。
Objective:To improve the quality of medical records writing; Methods:By comparing with the pros&cons of electronic medical records and the traditional hand-written medical documents quality of medical records, the appear-ance of quality defects situation; Results:The reality of electronic medical records defeats are more than written medical records, the authenticity of the defects of traditional hand-written medical record archives of timeliness, completeness, the emergence of normative defect occurrence rate are more than electronic medical records;Conclusion:Electronic med-ical records existed replication non-standard use, template pasted to rely too much on, electronic signature and optional. Must be enhanced the sense of responsibility, perfect the system of electronic medical record quality control function, in order to strengthen the management of electronic medical record system function applications, to improve further the quality of electronic medical records. To enhance the consciousness of the written evidence, thus protecting the legitimate rights and interests of both doctors&patients.
