| 电子病案首页存在的问题及改进意见 |
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| 引用本文： | 林彩霞. 电子病案首页存在的问题及改进意见[J]. 中国医药导报, 2008, 5(24): 138-139 |
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| 作者姓名： | 林彩霞 |
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| 作者单位： | 广东省惠州市中心人民医院病案统计室,广东惠州,516001 |
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| 摘 要： | 目的：通过对电子病案填写的质量监控，规范病案首页的正确书写，提高病案书写质量。方法：对2006年5月～2008年2月出院的归档并进行质检的74458份病案统计，分析。结果：74458份电子病案首页有5325份存在问题，占7.2%。结论：加强各级医师认识病案填写的重要性，提高电子病案首页书写质量。
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| 关 键 词： | 电子病案 首页 问题 改进 |
Problem and improvement in the front sheet of the electronic medical record |
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| LIN Cai-xia. Problem and improvement in the front sheet of the electronic medical record[J]. China Medical Herald, 2008, 5(24): 138-139 |
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| Authors: | LIN Cai-xia |
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| Affiliation: | LIN Cai-xia (Department of Health Record Statiscal Huizhou Municipal Central Hospital, Huizhou 516001,China) |
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| Abstract: | Objective:By the quality monitoring of filling in the Electronic Medical Record,the correct filling in the front sheet of the medical record was standardized and the quality of filling-in was improved.Methods:74 458 cases discharged from hospital between from May 2006 to Feb 2008 were statistical analyzed.Results:In these 74 458 cases,there were 5 325 defected cases,the rate was 7.2%.Conclusion:In order to improve the quality of the front-sheet in medical record,we should strengthen the consciousness of all doctors to make them know the importance of filling in front sheet correctly. |
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| Keywords: | Electronic medical record The front-sheet of medical record Problem Improve |
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