电子病案首页中存在的问题及对策

目的通过纠正电子病案首页中的填写错误,提高病案首页的质量。方法对病案首页录入过程中存在的主要问题进行相关调查分析。结果发现临床医生的首页填写、护士工作站的信息录入等存在诸多问题,提出加强科室沟通管理和质量监督检查、提高病案人员业务素质等措施。结论经过病案统计室与临床各个工作站及时周密地协调沟通,进一步完善电子病案首页的管理。

The Problems and Countermeasures in Electronic Medical Record Home

Objective To correct the mistake to improve the quality of electronic medical record home. Methods Home recording process on the list of the major problems in the conduction of the investigation. Results Clinicians found many issnes such as the home fillout,nurse stations and entry information,and proposed to strengthen communication and quality supervision and improve the quality of medical records staff. Conclusion Statistics department and clinical workstations timely well-coordinate and communicate to further improve the management of electronic medical records home.