电子病案版本升级对病案质量的提升

为了推进现代化医院的信息化,网络化管理水平,适应日益提高的医院的临床工作效率和医疗服务质量管理,我院于1998年实施了＂军字一号工程＂（Hospital information system简称HIS）,2000年我院运行了医师工作站1.46版,初步实现了信息化电子病案。该系统的顺利运行使临床医务人员从繁重的手工病案中解脱出来,提高临床工作效率和服务质量。该系统虽然方便快捷,但是具有可复制、可随意修改、缺乏对病案质量的自动监控等缺点。广州军区总医院开发了新的电子病案软件,较好地解决了这一问题。我院于2007年在保持原有医师工作站的功能和流程的基础上,实施了我院＂医师工作站系统＂的升级。新版医师工作站主要在原来电子病案的基础上,增加了对病历完成时限和病历内容的监控,以及对病历的评分系统,有效地促进了医疗管理水平的提高,规范临床病历、提高病案质量、减少医疗差错。

Update of Electronic Medical Records System Improves Medical Records Quality

In order to promote informationization of modern hospital and improve level of networking management,and to adapt to increasing clinical efficiency and medical service quality management,＂No 1 Military project＂（Hospital information system,HIS）was employed in our hospital in 1998,physician workstation（version 1.46）was operated in 2000 with initial implementation of the electronic medical records informationization.The system operated successfully,which released clinical medical staff from heavy handwritten medical records with improvement of clinical efficiency and service quality.Although this system is convenient and fast,but there are still some deficiencies,such as it is easy to replicate,it can be freely modified,it lacks automatic control to medical records quality.Guangzhou Military General Hospital developed new electronic medical records software,which resolves this problem better.Update of ＂physician workstation system＂ was applied in our hospital in 2007 based on its existing functions and processes.On the basis of original electronic medical records,new physician workstation mainly increased surveillance and control on finish time,contents and scoring system of medical records in order to effectively enhance medical management level,standardize clinical medical records,improve medical records quality and reduce medical errors.