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目的了解电子医嘱系统对医嘱书写规范的影响。方法按医嘱单书写规范标准,随机抽取2010年1月至10月1150份归档病案进行检查,其中试点电子医嘱病案461份,手写医嘱病案698份。结果电子医嘱单缺陷率35.8%;比手写医嘱单缺陷率低12.6%,减少或避免了手写医嘱的缺陷如药名书写不统一、缩写不规范、涂改、书写格式不规范和药品剂量不写等,但医嘱漏手工签名成为电子医嘱的主要问题。结论电子医嘱在书写质量、规范性方面优于手写医嘱,亟待电子签名的合法化,以解决签名问题。
Objective To understand the impact of the electronic medical order system on the written specification of medical orders. Methods According to doctor’s order written standard, randomly selected from January 2010 to October 1150 archived medical records for inspection, including 461 pilot electronic doctor case, 698 cases of handwritten doctor’s advice. Results The defect rate of electronic doctor orders was 35.8%. The defect rate was 12.6% lower than that of handwritten doctor orders, which reduced or avoided the defects of handwritten doctor ’s orders such as not uniform written drug name, nonstandard abbreviation, alteration, non - standard written form and dose not written. , But the doctor’s signature missed manual signature become the main problem of electronic doctor’s advice. Conclusion Electronic doctor orders are superior to handwritten doctor orders in terms of writing quality and normativeness, and legalization of electronic signatures is urgently needed to solve the problem of signatures.