电子病案环境下对纸质病案的管理

纸质病案在形成、归纳、存储过程中常存在漏项、缺页或遗失等问题，通过制定纸质病案交接要素表、病案质量检查登记表和病案归档信息反馈表，加强实时质控、环节质控和终末质控，以及建立奖罚制度等一系列管理方法，使医护人员责任心和病案书写质量得到进一步提高，杜绝纸质病案记录页的缺失，有效防范了医疗纠纷的发生。为保证病案资料完整性和真实性以及电子病案环境下纸质病案的管理提供可靠保证。

The Management of Paper-made Medical Records under the Enviroment of Electronic Medical Records

Paper-made medical records still has problems like lack of items,pages and lost during the process of formation,reduction and storage.Through setting up exchange element table of paper-made medical records,examination table of medical records quality and information feedback of medical records filing,we reinforce real-time quality control,segment quality control,final quality control and reward and punishment system.Therefore,the responsibility of medical staffs and writing quality of medical records have been further improved for precluding the lost of paper-made medical records and preventing effectively the occurrence of medical tangle.It provide reliable guarantee for making sure the completeness and truthfulness of medical records and the management of paper-made medical records under the environment of electronic medical records.