电子病案应用中存在的问题与改进措施

抽查我院3年来住院电子病案,发现在复制病历、粘贴病历时出现姓名、年龄、病变部位粘贴错误;使用电子病历模版时出现同病种患者记录内容雷同;处理医嘱时间和电脑后台记录时间不一致等问题。通过对上述问题进行分析,探讨改进病案书写质量的措施。提出采取完善制度管理,上级医师对下级医师书写的病案进行审签;并组织法律法规、病历书写等相关培训;增强法律意识、加强网络建设等相应措施,准确的把握病案书写质量的各个环节,确保电子病案质量的稳定和提升。

Improvement of Problems about EMR

This paper selectively examined hospitalization EMR in our hospital for resent three years finding out problems such as error of name,ages and lesion sites during copy and paste;similar content of the same disease category when using EMR template;the time of medical order was inconsistent with computer background time and etc.Through analyzing these problems,it discussed the countermeasures of writing quality of medical records,which were application of perfection systematic management;superior physicians signed medical record written by inferior physicians after evaluation;training about law and regulations and medical records writing;legal counsicouness and network contruction strengthening;accurate master segments of writing quality of medical records making sure the improvement of EMR quality.