摘要
目的:规避电子病历记录存在缺陷,确保病案信息的法律依据的客观性、真实性,确保医疗质量,杜绝医疗纠纷。方法统计分析我院2012年7~12月948份电子病历应用存在的缺陷。结果948份电子病历中有596份存在记录缺陷,缺陷率62.87%,主要为入院记录、病程记录、出院记录、医嘱单和病案首页记录缺陷。结论加强电子病历质量监控,是医院实施全面质量管理的关键环节,是一项不可以忽视的重要工作。
Objective to avoid the defects of electronic records,ensure objectivity,the legal basis for the medical record information authenticity,ensure the medical quality,to prevent medical disputes.Method Analysis of our hospital in 2012 7-12 month 948 in application of electronic medical record defect statistics.Results of the 948 electronic medical records of 596 existing record defects,defect rate of 62.87%,mainly for the admission records,records,hospital records,doctor's advice and medical record record defects.Conclusion to strengthen quality control is the key link of hospital electronic medical records,the implementation of total quality management,is an important work can not be ignored.
作者
李亚玲
李明
毕珍
赵越
张瑜珊
LI Ya-ling;LI Ming;BI Zhen;ZHAO Yue;ZHANG Yu-shan(Kunming City Children's Hospital Medical Department,Kunming Yunnan 650228,China)
关键词
电子病历书写质量
缺陷分析与对策
病案管理质量
Electronic medical record writing quality
Defects analysis and Countermeasures
The quality of medical record management
