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目的临床使用电子病历发生常见错误的预防方法。方法我院对于临床科室在电子病历长期临床使用过程发现克隆病历、复制错误、各种讨论简单,手术记录缺乏客观性的4个方面的常见错误进行分析,通过认真分析取得正确的预防措施,对于预防措施进行逐项落实,使电子病历的常见错误明显减少,充分体现电子病历的快捷,精确,高效的特点。结果电子病历使用过程中发现共性错误的预防措施进行改进,摸索预防方法,使电子病历的合格率明显提高。结论我院多年来对电子病历的共性错误进行了专业的研究并提出改进意见,使电子病历的常见错误的发生率由改进预防措施前的8%,降低为2%以下。
Objective Clinical use of electronic medical records common mistake prevention methods. Methods The clinical departments in the clinical use of electronic medical records in the long-term clinical use of clonal records, copy errors, a variety of discussions is simple, the lack of objectivity in the surgical records of the four aspects of the analysis of errors, through serious analysis to obtain the correct preventive measures, for Preventive measures were implemented one by one, so that the common errors of electronic medical records significantly reduced, fully embodies the electronic medical records of the fast, accurate and efficient features. Results In the process of using electronic medical records, common precautionary measures for detecting common mistakes were made to improve the method of prevention, and the passing rate of electronic medical records was significantly improved. Conclusions Our hospital has conducted professional research on common mistakes of electronic medical records and put forward suggestions for improvement over the years. The incidence of common mistakes in electronic medical records has been reduced from 8% before preventive measures to below 2%.