临床医生使用电子病历存在问题与对策

Problems Existing in Electronic Medical Records Used by Clinicians and Relevant Countermeasure

随着医改进程的不断深化,电子病历系统的应用是医疗信息化建设的重要举措,国家目前大力推广电子病历系统的普及,但与电子病历快速、迫切发展相违背的是很多临床医生对电子病历认识不足及存在很多误区,在使用过程中存在概念认识不足、没有正确理解电子病历的真正意义、不能充分利用电子病历结构化这一特征等等问题,针对这些问题提出相应的解决办法和实行对策,如:加强宣传与培训、陈述电子病历临床使用的法律问题、如何提高电子病历的功能等。在不断深化医疗改革的进程中,无论医院领导或临床医生,只有从思想上高度重视,才能积极配合,快速发展电子病历系统,从根本解决问题,制定整体规划和目标,规范化和标准化电子病历,促进信息共享的发展。

As the continuous deepen of medical innovation process, the application of electronic medical record system is an important measure to the construction of medical informatization. Now the nation is popularizing electronic medical record system vigorously, but many problems were contrary to the rapid and urgent development of electronic medical record, such as insufficient understanding on electronic medical record among chniciaus or existing many misunderstanding, insufficient understanding of concept in the process of using, wrong understanding on the real significance of electronic medical record and unable to take full use of the structuring character of electronic medical record. Aimed at these problems, we put forward relevant solutions and such as strengthen publicity and training, state the law questions in the using of electronic medical record and how to improve the function of it. In the process of deepening medical reform, only through paying high attention inwardly both leaderships and clinicians can we cooperate positively in the development of electronic medical record system, then we can solve problems fundamentally, formulate total planning and goals, normalize and standardize electronic medical, after all promoting the development of information sharing.