摘要
目的随着CPR应用的不断深入,其管理和使用过程中的有关问题逐步暴露出来,如何确保CPR信息准确、安全,保持其原始性、真实性,是电子病历开发、使用者和医院管理者高度重视的课题。在电子病力使用过程中存在的主要问题是程序和电子病历模板设计不完善、智能化程度低、病历内涵和外在质量问题较多(病历的客观真实性受到挑战,病历内容的雷同化现象,存在严重的质量缺陷,病案首页信息不规范,打印质量问题,His网上数据欠准确)、保密设置功能不完善、医-护之间的脱节现象、病历的存储和流通格式有待规范。方法为此需要采取如下措施:不断完善电子病历源程序;建立智能化平台;建立网络模式下新的病案监控手段和管理方式、加强HIS网上数据监控、开发电子病历质量监控软件、健全电子病历的安全防范措施等。结果电子病历质量明显提高。
Objective With aplication of the computer - based patient record (CPR), its management exposes out gradually with the relevant problem that use the process inside, how to ensure the information of CPR, safety, its primitive, reliability in keeping is lesson that computer - based patient record development, user with hospital the governor values highly. The key problem exsited in computer - based patient record use process is a procedure to design with the computer - based patient record template not perfect. The intelligence turns the degree low. The medical record content is more with the outside quantity problem. The objective reliability of the medical record suffers the challenge, medical record contents of similar turn the phenomenton, exsit serious quantity blemish, medical record page first information not norm, print the quantity problem, on the His net the data ows accurate. Keep secret to establish the function is not perfect. Cure the dislocated phenomenon of the of nurse. Medical record of saving with circulate the format need the norm. Method Adopt for this demand as follows measure: Continuously perfect computer - based patient record source procedure. Establishing the intelligence turns the terrace. Establishing the next new medical record in netweork mode supervises and control the means with manage the way. Enhancing the HIS net top data supervises and control. The development computer - based patient record quantity supervises and control the software. The safety of the sound computer - based patient record againsts measure etc. Result somput-er - based patient record quantity is obvious to increase.
出处
《中国卫生质量管理》
2005年第2期61-62,60,共3页
Chinese Health Quality Management
