探讨医院电子病历模式下病案管理质量的缺陷

摘要

Objective To summarize the clinical medical record quality defects and corresponding control strategy under the electronic medical record management. Methods A retrospective analysis of our hospital 3200 copies of electronic medical record writing situation,summarizes its quality defects. Results There are 320 copies of quality defects,accounting for 10%,mainly for the basic information to fil in error,the lack of integrity of the information recording,not reflected diseases diagnosis,diagnosis wrong choice etc. Conclusion Although the electronic medical record plays an important role in raising the quality of the medical record,but stil need to do the corresponding quality control measures,reduce quality defects.%目的：总结在电子病历管理下，临床病案存在的质量缺陷与相应控制策略。方法回顾性分析我院3200份电子病历书写情况，总结其存在质量缺陷。结果有320份存在质量缺陷，占10%，主要表现为基本信息填写错误、缺乏完整的信息记录、未体现疾病诊断依据、诊断选择错误等。结论虽然电子病历对提高病案质量有着重要作用，但仍需做好相应的质量控制措施，减少质量缺陷。