摘要
目的寻找提高电子病案质量的有效方法。方法询问病历返修者和电脑工程师并综合分析,发现转换成电子版纸病案过程的不规范病历是源于初始电子病案不规范的写与印,通过全员培训,学习电子病案制作规程,制定合理病案流程,加强沟通等措施管理初始痛案。结果提高了病案质量。结论加强初始电子痛案管理是提高电子病案质量的有效方法。
Objective Look for the effective method to improv the quality of electronic medical records. Method Ask the medical record repair and computer engineer and comprehensive analysis, found that convert softcopies paper records process is not standard medical record is originated from the initial electronic medical record non-standard writing and printing, employee training, learning through electronic medical record production procedures, formulate rational medical procedures, strengthen communication management measures such as initial records Results Improved medical quality. Conclusion Strengthen management in initial electronic medical records is effective methods to improve the quality of electronic medical recoFds .
作者
罗晓玲
LUO Xiao-ling (Medical records department of children's hospital of women and children's medical center in Guangzhou, Guangzhou 510120 ,China)
出处
《医学信息》
2011年第20期6690-6691,共2页
Journal of Medical Information
关键词
初始电子病历
质量
管理
initial electronic medical records
quality
management