中国病案
中國病案
중국병안
CHINESE MEDICAL RECORD
2013年
1期
49-50
,共2页
电子病案%质量问题%对策
電子病案%質量問題%對策
전자병안%질량문제%대책
Electronic medical record%Quality problem%Countermeasures
对休养员疗养进行记录的电子病案进行网上检查和归档后的随机抽查发现存在过分依赖复制、粘贴和拷贝,书写不及时、时间不准确,打印归档不及时等问题.主要原因是医务人员责任心不强,法律意识淡漠,质控力度不够.采取针对性措施:强化责任意识,完善病案管理制度,加强法律法规意识,完善电子病案监控功能,才能提高电子病案的质量.
對休養員療養進行記錄的電子病案進行網上檢查和歸檔後的隨機抽查髮現存在過分依賴複製、粘貼和拷貝,書寫不及時、時間不準確,打印歸檔不及時等問題.主要原因是醫務人員責任心不彊,法律意識淡漠,質控力度不夠.採取針對性措施:彊化責任意識,完善病案管理製度,加彊法律法規意識,完善電子病案鑑控功能,纔能提高電子病案的質量.
대휴양원요양진행기록적전자병안진행망상검사화귀당후적수궤추사발현존재과분의뢰복제、점첩화고패,서사불급시、시간불준학,타인귀당불급시등문제.주요원인시의무인원책임심불강,법률의식담막,질공력도불구.채취침대성조시:강화책임의식,완선병안관리제도,가강법율법규의식,완선전자병안감공공능,재능제고전자병안적질량.
Some problems such as depend on copy ,paste and copy ,w riting not timely ,time is not accurate and print file not timely ,etc .were found by online inspection and random inspection .The main reasons were the sense of responsibility is not strong ,legal consciousness indifference ,and quality control is not strong enough .We should strengthen the responsibility consciousness ,perfect medical record management system ,and strengthen the consciousness of laws and regulations and perfect electronic medical record monitoring function to improve the quality of the electronic therapy .
