电子病案质量缺陷原因分析与对策

电子病案常见质量缺陷包括病人基本资料缺漏,出院诊断选择错误,病程记录拷贝现象严重,诊断及鉴别诊断分析过于简单,病案过于框架化简单化。影响电子病案质量主要原因包括病案书写模式的改变,医师的综合素质能力,医务人员工作责任心,医务人员法制观念,医院重视程度。提高电子病案质量的对策包括加强医师规范化培训,建立电子病案的评审标准,确立以环节质控为主的实时质控及专家评审制度,定期举行电子病案质量检查与质量讲评。

Analysis and Countermeasures on Quality Defects Reasons of EMR

Common quality defects of the EMR include lack of the patient’s basic information,wrong choice of hospitalization diagnosis,serious copy of the course record,simple analysis of the diagnosis and differential diagnostic.The main factors affecting the quality of EMR include the change in the writing mode of medical records,physicians’ comprehensive ability,sense of responsibility of the medical staff,the legal concept of medical personnel and hospital attention and etc.The countermeasures of improving EMR quality that includes the standardized training of doctors strengthening,evaluation standard of EMR establishment,establishment of real-time quality control focus on segment quality control and experts evaluation system,and regular holding quality inspection of EMR and quality commenting.