| 电子病案在医疗质量控制中的作用 |
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| 引用本文： | 钟秋霞. 电子病案在医疗质量控制中的作用[J]. 中国现代医生, 2008, 46(20): 128-129 |
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| 作者姓名： | 钟秋霞 |
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| 作者单位： | 广东省惠州中心医院病案室,广东惠州,516001 |
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| 摘 要： | 目的探讨电子病历在医疗质量控制中的作用。方法按《病历书写基本规范》对电子病历进行管理，将有明确时限要求的30项内容作为病历质量的“单项否决”的条件。结果实现法律法规对病案的要求；加强病案的管理权限及病历质量的规范性；做好病历环节质量的实时控制。结论电子病案在医疗质量控制中有明显作用，保证电子病案的合法性及法律效应。
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| 关 键 词： | 电子病案 电子签名 质量管理 |
The Role of Electronic Medical Record in the Medical Quality Control |
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| ZHONG Qiuxia. The Role of Electronic Medical Record in the Medical Quality Control[J]. , 2008, 46(20): 128-129 |
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| Authors: | ZHONG Qiuxia |
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| Affiliation: | ZHONG Qiuxia(Department of Record Room, Huizhou Central Hospital, Guangdong 516001) |
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| Abstract: | Objective To investigate the role of electronic medical records in quality control. Methods According to the ＂basic norms of written records,＂ the management of electronic medical records,there will be a clear time limit for the 30 medical quality of the content as ＂single veto＂ conditions. Results of laws and regulations to achieve the requirements of cases,and strengthening the medical record management authority and norms of the quality of medical records;link to the quality of medical records real-time control. Conclusion Electronic medical record has marked significance in the medical quality control in ensuring that the legitimacy of electronic medical records and legal effect. |
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| Keywords: | Electronic medical records Electronic signatures Quality Management |
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