电子病历模式下中医病案质量缺陷及探究

Quality Defects Exploration on Traditional Chinese Medicine Medical Records under Electronic Medical Records Mode

总结了在电子病历模式下中医病案质量缺陷要点,包括计算机输入错误,四诊信息记录不完整或表达不准确,中医辨病辨证依据没有在病程记录中得到体现,诊断的选择不准确;病案质量缺陷的原因有,计算机技术应用改变了病历书写模式,对医疗风险重视不够,临床医生对病历中中医辨证论治内容书写不够重视;最后讨论了提高保证病案质量的措施。

This article summarized the quality defects existing in traditional Chinese medicine medical records under electronic medical records mode, such as computer input errors, incompletely recording of diagnosis information or inaccurate expression, the character of differentiation and discrimination accordance of traditional Chinese medicine had not reflected in the progress notes and inaccurate choice of diagnosis. The reasons of the quality defects included that the application of computer technology changed the writing mode of medical records, lack of emphasis on the risks existing in medical treatment and clinicians attached less importance to the character of differentiation and discrimination content of traditional Chinese medicine, at last we discussed measures to improve the quality of medical records.