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随着电子计算机技术的普及及应用,电子病案已成为医疗信息载体发展的必然趋势。我院自二二年起实施计算机化病案信息系统以来,给医务人员带来了方便和快捷,节省了时间,提高了工作效率。电子病案的运用解决了手写病案字迹潦草、刀刮、涂改等问题,但同时又出现了更为严重的复制问题。针对这一新的问题,我院病案质量管理委员会采取了一系列相应的措施,降低了病案缺陷率,保证了病案质量,取得了较满意的效果。
With the popularization and application of electronic computer technology, electronic medical record has become the inevitable trend of development of medical information carrier. Since our hospital implemented the computerized medical records information system since 2002, it has brought convenience and speed to medical personnel, saved time and improved work efficiency. The use of electronic medical records has solved the problems of handwritten medical records illegally written, knife scraping, alteration and so on, but at the same time, more serious duplication problems have emerged. In response to this new issue, our hospital medical records quality management committee has taken a series of corresponding measures to reduce the rate of medical record defects, ensure the quality of medical records, and achieved more satisfactory results.