医院电子病案风险管理研究

摘要

By interview with medical staff, questionnaire and general research methods, risks of hospital electronic medical record in law, safe and integrity were analyzed. Suggestions such as improving law and regulation system, strengthening legal risk concept, strengthening software, hardware and internet safety control, electronic medical record edition right and password safety control, electronic medical record content and sign safety control, establishing electronic medical record process quality test system, eliminating fragmentary medical record from headstream, establishing strict reward-punishment mechanism and electronic medical record standardization control are presented to improve electronic medical record risk management.%通过对某医院医务工作者的访谈、问卷调查和综合研究等方法,分析当前医院电子病案风险管理的必要性及面临的法律性、安全性、完整性等各种风险,并提出完善现有法律法规、增强法律风险意识、做好软硬件及网络技术安全控制、电子病案书写权限及密码安全控制、电子病案内容及签名的安全控制、建立电子病案环节质量检查制度、堵塞残缺病案的源头、建立严格的奖惩制度、电子病案标准化控制等相应的对策,以促进医院电子病案风险管理水平不断提高.