提高电子病历内涵质量的对策和做法

Countermeasure and Practice of Improving Connotative Quality of Electronic Medical Records

目的:探讨如何提高电子病历的内涵质量。方法:回顾电子病历的优势及常见缺陷,结合实际工作中提高内涵质量的办法,提出一些建议。结果:制定具体质量标准,落实科内环节质控和专家专业对口重点质控,同时利用信息化平台的监控方法,可提高电子病历的内涵质量。结论:提高医院整体医疗水平是提高病历内涵质量的关键。

Objective To explore connotative quality of how to improve the electronic medical records. Methods Combiningwith the ways of improving connotative quality in fact, the advantages and common defects of electronic medical records were reviewed and some suggests were brought forward. Results The connotative quality of electronic medical records could be enhanced by specific quality standards, the implementation of quality control of section links and the emphasis quality control suited to expert＇s specialty, at the same time, the connotative quality of electronic medical records was raised by monitor methods of informationazition platform. Conclusion Improving the whole medical level of hospitals is the crux of raising the connotative quality of medical records.[Chinese Medical Equipment Journal, 2009,30（3） ： 51-52]