新管理规范背景下急诊电子病历存在的问题及改进举措

Discussion on problems and countermeasures of emergency electronic medical records in the background of new management standard

首都医科大学宣武医院急诊病历经历了从纸质向电子病历过渡,正处于电子病历向无纸化过渡阶段,在实践过程中面临许多新的问题与风险。通过进一步梳理风险点,以问题为导向,结合急诊工作的特殊性,加强信息化改进方便临床操作,依托信息化强化病历书写规范化管理,探索急诊电子病历质量与风险管理的新思路。

Xuanwu hospital emergency medical record has experienced the transition from paper to electronic, which is in a stage of transition to a paperless electronic medical record.However,there are many new problems and risks in the process of practice.In order to avoid medical faults,muti-methods should be adopted to daily practices, and combined with the particularity of emergency work,strengthening the informationization improvement in clinical work,relying on the information to strengthen the standardized management of medical record.It shows a great effectiveness on electronic medical record quality and risk management.