电子病案质控存在的问题及改进措施

通过分析电子病案书写中暴露的复制粘贴、病案首页录入缺陷、病历记录不规范、嗣手术期病历记录缺陷等问题，依据《病历书写基本规范》，结合电子病历书写的及时性、完整性、真实性及相关医疗文书填写的规范要求，查找主管和客观的原因，提出病案质控要绷紧病历质量弦、落实质控责任“链条网”、盯住重点筑牢“防火墙”、构筑病案归档“高压线”、重奖惩激活内在“动力泵”等的改进措施，力争达到医疗质量管理科学、规范、安全要求。·

Problems Existing in the Quality Control of Electronic Medical Records and Relevant Improvement Measures

To analyze problems exposed in the writing of electronic medical records such as copy and paste, defieiency in the type-in of home pages, not standardized recording and defects in the recording of perioperative period medical records. According to the ＂Basic Norms of Medical Records Writing＂, combined with the requirements of electronic medical records such as timely, integrity, authenticity and the requirements of related medical records writing. Through improvement measures such as find out ＂the subjective and objective rea- sons, put emphasis on the medical records quality in the quality control, put quality control responsibility into practice, pay attention on the key points, establish medical records pigeonhole rules and strengthen rewards and punishment and so on, so as Io reach the medical quality management requirements of science, standard and saffety.