我院在电子病历质量控制方面的实践

摘要

Through full investigation on medical workers’ case writing habit and core module of the structured electronic medical records, a set of electronic medical record quality control system is designed for practical application. It has been enhanced in terms of practicability and ease of use, plays an important role in increasing work efficiency, improving quality of medical records as well as data safety.%本文通过对临床医务人员书写病历的操作习惯、工作方式等方面的充分调研，利用结构化电子病历的核心模块，通过多个周期不断的迭代，设计出了一套切合实际应用的电子病历质量控制体系。该系统在实用性及易用性方面得到了增强，提高了医院的病历质量，在帮助高效工作、提高病历质量、保障数据安全等方面发挥重大作用。