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我院于2000年应用电子病案系统,极大地提高了临床工作效率。但病历终末质量有所下降。为了提高病历书写质量,病案科通过发放调查问卷,征集问题,并结合电子病案对不良拷贝、滥用电子病案模板、内涵质量不高、遗漏项目、书写内容不准确等存在的常见问题,进行原因分析,制定了病案质量重点监察制度、病案质量月通报制度、医护人员病案书写质量个人档案制度等相应对策,使病历质量得到了大幅度提高。
Our hospital in 2000, the use of electronic medical record system, which greatly improved the efficiency of clinical work. However, the quality of medical records has declined. In order to improve the quality of medical record writing, the case record department collects questions by issuing questionnaires and combining with the common problems of bad copy, abuse of electronic medical record templates, low content quality, missing items and inaccurate contents of writing, and so on. , Developed a focus on the medical record monitoring system, medical record quality monthly notification system, medical records and personal medical record quality personal file system and other appropriate measures to make the medical record quality has been greatly improved.