电子病历档案缺陷与对策

Defects and Countermeasures of Electronic Medical Record

目的探讨电子病历档案缺陷与管理。方法对电子病历档案管理各个环节中的缺陷进行分析。结果论述了电子病历档案的真实性、准确性、安全性,并提出了电子病历档案的规范管理的对策。结论加强规范化培训,强化质量、责任、法律意识,逐级把关提高病历质量。

Objective To study the electronic medical record and management deficiencies. Methods All aspects of electronic medical record management deficiencies were analysed. Results Explain the electronic medical record on the authenticity, accuracy ,security, and put forward to the norms of the electronic medical record management solutions. Conclusion Strengthen standardization training,and enforce the quality, responsebility, awareness of the law, and explained gatekeeper improve the quality of medical records.