摘要
目的：对计算机打印病历的常见问题进行整理并分析，制定相应解决策略，提高计算机打印病历整体质量。方法搜集我院2011年12月~2013年12月部分计算机打印病历，共950份，依据《病历书写基本规范》的原则对病历进行整理，结果汇总，查找常见问题原因及制定相应对策。结果950份病历中共有406份存在问题，主要集中在病历书写不规范282份，病历记录不完整208份，病历复制错误192份，病历记录不准确150份，并制定相应改进对策。结论计算机打印病历是病案管理的发展趋势，合理应用计算机，认真负责填写病历，将大大方便临床工作。
Objective To clear up and analyze the common problems of computer-printed medical records, develop corresponding solving strategies, and improve the overall quality of computer-printed medical records. Methods A total of 950 copies of computer-printed medical records of our hospital from December 2011 to December 2013 were collected and cleared up based on the principles of ＂Essential Requirements of Medical Records Writing＂. Then the results were summarized, causes of common problems were sought out and corresponding measures were developed. Results Of the 950 copies of medical records, 406 copies had problems, including 282 copies of unstandardized medical records writing, 208 copies of incomplete medical records, 192 copies of medical records replication mistakes, and 150 copies of inaccurate medical records. Corresponding improving countermeasures were developed. Conclusion Computer-printed medical records are a development trend of medical records management. Rational application of computers and serious and responsible medical records writing will largely facilitate clinical work.
出处
《中国医药科学》
2014年第8期155-157,共3页
China Medicine And Pharmacy
关键词
计算机
病历
病案管理
提高对策
Computer
Medical records
Medical records management
Improving countermeasures
