摘要
伴随着现代信息科学技术的高速发展,高智能化、数字化的电子病案已经成为病案信息管理发展的趋势,并将逐步代替传统的手工书写病历,成为未来卫生信息管理主要手段。采用登录医师工作站并在国际疾病分类数据库项目中选取疾病的方式来填写诊断,电子病案使首页出院诊断填写更标准化。病案首页的填写质量直接影响着统计报表的准确性。本研究通过两年时间的工作实践,对肿瘤科医师选取主要诊断所出现的问题进行分析,总结归纳出一套方法,从而逐步提高医师在电子病案首页选取出院诊断的技能,提高电子病案质量。
Along with the fast development of modern information science and technology,high intelligence and digital electronic medical record has become the trend of the development of the medical record information management to become the main means of health information managementin the future,and will gradually replace the traditional manual writing medical records.By loginning into doctor workstation and the diagnosis are filled in the way of selecting disease from the database project of the international diseases classification. Electronic medical record made the diagnosis filled in home page more standardized. The writing quality of Medical record home pagedirectly affectes the accuracy of the statistics.This study through two years’ work practice,by analysis the problems of selecting primary diagnosis from doctors in oncology and summarizes a set of methods to gradually improve physicians skills in selecting hospital dis-charge diagnosis by using electronic medical record and the quality of electronic medical record.
出处
《中国当代医药》
2015年第29期173-175,共3页
China Modern Medicine
关键词
电子病案首页
恶性肿瘤
出院诊断
对策
Front sheet of electronic medical records
Pagein cancer patients
Discharge diagnosis
Countermeasure
