网上病历的质量现状分析

经对医院网上的在院病人病历的调查分析发现，网上病历存在一些问题，表现是不适当的复制，不能按时限要求完成病历书写内容，反映出医疗环节质量管理存在缺陷，使病历的真实性，准确性降低，失去了病历在医，教，研，法律，医疗保险等方面的使用价值。因此，提高临床医生对网上病历质量的认识，加强其责任心和法律知识的教育，建立有效的病历质量实时监控管理办法，加快结构化电子病历的研究和利用是改善现状的关键。

Analysis of the present situation about medical record quality in network

Through the investigation about the hospitalized patients' medical records in network,some problems in our hospital were found. The main issues of these problems were the duplicating medical records impertinently in local area network and the finishing the medical record contents later than the requested. Those might revealed the unperfected situation in the medical quality administration, decreased the reality and actuality of the medical records, and lowered the utility value in the area of medical therapy,education,research and insurance and law. Thus,the key measures of improved present situation were enhanced the clinician' s knowledge about the network record quality, strengthened the education for the responsibility and legal duty, built a real -time effective management system for the record quality and quickened the research and application of structural electrical medical record system.