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计算机打印病案在带来办公便捷的同时,也带来了一些新的问题。通过质控检查,发现主要问题既有有电子系统程序的缺陷,也有实际应用操作的问题,如病历模板的设计使用、打印机的打印质量、计算机打印完成的病历缺少手工签字等。针对问题及时采取措施,三级质控互动,一级质控三级医师各司其职;二级质控份份把关,并及时反映问题;三级质控监督检查并解决程序问题。最终病历质量有了明显的提高。
While computerized medical records bring convenience to the office, they also bring some new problems. Through quality control inspection, it was found that the main problems are not only the defects of the electronic system program, but also the problems of practical application and operation, such as the design of the medical record template, the print quality of the printer and the lack of manual signature of the medical records completed by the computer. Timely measures to address the problem, the three quality control interaction, a quality control level three physicians perform their duties; two quality control checks, and promptly reflect the problem; three quality control supervision and inspection and resolution of procedural issues. The final medical record quality has been significantly improved.