提高门诊电子病历质量方法

Measures of improve the outpatient electronic medical record' s quality

门诊电子病历是数字化医院的重要标志之一,其质量至关重要。本文提出了门诊电子病历目前存在的问题,有针对性地提出解决对策,包括:优化门诊处方设计,加强用药安全;规范录入语言格式,改变存储方式,方便信息利用,增加电子储贮内容,力争与纸质病历相同;强化规章制度管理,确保电子病历安全性;提高电子病历"三性",最大限度保障法律地位,定期维护相关数据,满足"以人为本"要求;加大质量监管力度,全面提升病案质量。只有门诊电子病历质量提高,医院方能健康全面发展。

Outpatient EMR is one of the important symbols in digital hospital. Its quality is important. The paper not only described current problems of EMR, but also proposed corresponding measures. These measures included that optimizing the design of outpatient prescription, strengthening the safety of drug, ruling the format of input, changing the fashion of saving, expediting the usina of information, aggregating correlation system, increasing electronic data content to be identical with traditional medical records, enhancing rules and regulations management to safeguard its security, strengthening EMR＇ s validity, rationality and correlation to provide the legal guarantee as more as possible, Maintaining relevant data regularly to meet needs of ＂human oriented＂, reinforcing the supervision power of quality to improve the quality of medical records. The hospital would realize sustainable development, only if the quality of EMR was irnproved. As the quality of outpatient EMR improved, the hospital can develop healthy and all around.