CAJ | 학술논문

门(急)诊病案管理的主要缺陷由现行门(急)诊病案管理模式的弊病造成,在电子病案远不能普及、门(急)诊病案的管理模式还不可能发生根本性转变的背景下,门(急)诊病案要需努力做到病历书写要体现患者个人信息的完整性、体现病历记录内容的完整性、体现核心制度落实情况、体现医疗告知与门诊随诊等内容,更好地防范医疗纠纷.
문(급)진병안관리적주요결함유현행문(급)진병안관리모식적폐병조성,재전자병안원불능보급、문(급)진병안적관리모식환불가능발생근본성전변적배경하,문(급)진병안요수노력주도병역서사요체현환자개인신식적완정성、체현병력기록내용적완정성、체현핵심제도락실정황、체현의료고지여문진수진등내용,경호지방범의료규분.
The major defects of outpatient and emergency medical record management are caused by the malady of current outpatient and emergen-cy medical record management mode .The writing of outpatient and emergency medical record should reflect the integrity of the patients personal infor-mation ,reflect the integrity of the medical record content ,reflect the core system implementation and reflect medical informed and outpatient fol ow-up ,etc w hen the electronic medical record is not universal ,and the management mode is impossible to change radical y .Final y better to prevent medi-cal disputes .