论文部分内容阅读
病案是医疗文件。是对疾病的发生、发展、治疗、转归客观、全面、系统的科学记载。随着计算机的广泛应用,电子病案的普及,电子病案中存在的问题也突显出来,经对我院电子病案近年来的观察发现,电子病案存在的主要问题是:不适当的复制、不按时间要求完成,直接反映出医疗环节质量管理存在问题,使病案的真实性、准确性大大降低,失去了病案在医、教、研、法律、保险等方面的实际应用价值。病案质量的管理是医疗管理的重要组成部分,因此,加强对电子病案环节的质量管理,加强对医师的职业道德培训,提高医务人员的整体素质,建立有效的质控管理体系,加快监控软件的开发和利用,是全面提高病案质量的关键所在。
Medical records are medical documents. It is an objective, comprehensive and systematic scientific record of the occurrence, development, treatment and transfer of the disease. With the widespread use of computers and popularization of electronic medical records, the problems existing in electronic medical records are also highlighted. In recent years, electronic medical records in our hospital have found that the main problems with electronic medical records are: improper copying, The completion of the request directly reflects the existing problems in the quality control of the medical sector, greatly reducing the authenticity and accuracy of medical records, and losing the practical value of medical records in medical, teaching, research, legal and insurance fields. The quality of medical record management is an important part of medical management. Therefore, it is necessary to strengthen the quality management of electronic medical records, strengthen the training of physicians on professional ethics, improve the overall quality of medical personnel, establish an effective quality control management system and speed up the monitoring software Development and utilization, is the key to improving the quality of medical records.