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目的探讨电子病案应用初期未归档纸质病案缺陷的原因。方法选择2013年2月本院患者出院时送到病案室的未归档纸质病案916份,病案室护士在整理、排序、装订的过程中对病案初步把关,把缺陷项目详细登记、汇总、分析,查找出缺陷的原因。结果针对产生病案缺陷的原因,采取加强医务人员相关法律法规知识的培训及改变患者出院流程等措施。结论以上措施使病案缺陷问题明显减少,取得满意效果。
Objective To explore the reasons for the failure of filing paper medical records in the early stage of electronic medical records. Methods A total of 916 unpatched paper-based medical records were collected from hospital patients who were discharged from hospital in February 2013. The record nurses conducted preliminary checks on the medical records during the process of sorting, sorting and binding, and detailedly registered, summarized and analyzed the defects , Find out the reason for the defect. Results In view of the causes of the medical record flaws, some measures were taken to strengthen the training of medical personnel about the laws and regulations and to change the patient discharge process. Conclusion The above measures have significantly reduced the number of medical record defects and achieved satisfactory results.