电子病案终末质量缺陷原因分析及对策

我院于2000年应用电子病案系统，极大地提高了临床工作效率。但病历终末质量有所下降。为了提高病历书写质量，病案科通过发放调查问卷，征集问题，并结合电子病案对不良拷贝、滥用电子病案模板、内涵质量不高、遗漏项目、书写内容不准确等存在的常见问题，进行原因分析，制定了病案质量重点监察制度、病案质量月通报制度、医护人员病案书写质量个人档案制度等相应对策，使病历质量得到了大幅度提高。

Cause Analysis and Countermeasures of Defects of Terminal Quality of Electronic Medical Records in our hospital

The efficiency of clinical work has been greatly improved since the use of electronic medical records system from 2000 in our hospital.But the terminal quality of medical records has decreased since then.In order to improve the quality of medical records writing,medical records department analyzed the cause of it,through sending questionnaires,collecting issues,and considering the common problems in electronic medical records,such as bad copies,abuse of templates,low content quality,missing items,inaccurate...