| 电子病案监管防范医疗纠纷 |
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| 引用本文： | 赵倩,劳海彬,王海永,杜振宗,夏学巍.电子病案监管防范医疗纠纷[J].中国病案,2010,11(9):11-12. |
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| 作者姓名： | 赵倩 劳海彬 王海永 杜振宗 夏学巍 |
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| 作者单位： | 1. 广西桂林医学院附属医院病案室,桂林市,541001
2. 广西桂林医学院附属医院外科学教研室,桂林市,541001 |
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| 基金项目： | 本课题受桂林医学院教学科研立项课题青年专项基金 |
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| 摘 要： | 目的探索电子病案质量管理的有效方法,提高电子病案质量。方法分析电子病历书写中出现的问题,指出容易产生医疗纠纷的原因。结果针对电子病案在医疗纠纷诉讼中的重要作用,提出在电子病案的书写过程中要做到真实、及时的反映医疗行为,从而减少医疗纠纷的发生。同时还应在技术层面对电子病案加强监管。结论加强电子病案质控管理是减少医疗纠纷的重要因素。
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| 关 键 词： | 电子病案 医疗纠纷 监管 |
Strengthen Supervision on Electronic Medical Record and Prevent Medical Disputes |
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| Zhao Qian,Lao Haibin,Wang Haiyong,Du Zhenzong,Xia Xuewei.Strengthen Supervision on Electronic Medical Record and Prevent Medical Disputes[J].Chinese Medical Record,2010,11(9):11-12. |
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| Authors: | Zhao Qian Lao Haibin Wang Haiyong Du Zhenzong Xia Xuewei |
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| Institution: | ,Surgery Teaching and Research Department of Affiliated Hospital of Guilin Medical College,Guilin 541001,Guangxi Zhuang Autonomous Region,China |
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| Abstract: | Objective To investigate the effective methods for quality management of electronic medical record in order to improve its quality. Methods The problems existed in the writing of electronic medical record were analyzed to indicate the reasons contributing to medical disputes. Results on basis of the importance of electronic medical record in medical dispute lawsuit,medical behaviors should be truly and timely reflected in the writing of electronic medical record to reduce medical disputes,in addition,monitor for electronic medical record should also be enhanced on the technique level. Conclusion Strengthening the quality control of electronic medical record is a dominate factor to reduce medical disputes. |
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| Keywords: | electronic medical record medical dispute monitor |
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