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目的探讨电子病案书写过程中存在的复制问题。方法将我院自2002年使用电子病案以来,病历终末质检过程中发现的病历复制问题做一总结。结果电子病案存在着严重的复制问题。结论限权复制,加强管理,加强医务人员的法律意识、责任意识,强化病案书写过程的环节质量管理,对复制病历制定严格惩罚制度,能减少电子病历的复制,提高病历书写质量。
Objective To explore the problem of duplication in the writing of electronic medical records. Methods Since the use of electronic medical records in our hospital since 2002, the medical records replication problems discovered during the final medical records review have been summarized. As a result, there are serious duplication issues with electronic medical records. Conclusions Restrictions on copying, strengthening management, strengthening medical personnel ’s legal awareness and responsibility awareness, strengthening the quality management of medical record writing process and setting strict punishment system for copying medical records can reduce the duplication of electronic medical records and improve the quality of medical records writing.