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我院建立医生工作站以后,实现病案首页计算机管理,废除了以往手工抄写的疾病和手术索引卡,入院和出院登记本。出院诊断由主管医生录入,既敦促医生努力学习并掌握国际疾病分类的知识,也使我院的出院诊断书写更加规范。加强了病案首页填写的质量控制,使从计算机获取的信息更真实、快捷。
After setting up a doctor’s workstation in our hospital, we realized the computerized medical records homepage, abolished the handwritten transcriptions and surgical index cards, and registered and discharged patients. Discharge diagnosis by the competent doctor input, both urging doctors to study hard and master the knowledge of the international classification of diseases, but also to our hospital discharge diagnosis more standardized. The quality control on the front page of the medical record has been strengthened so that the information obtained from the computer is more realistic and faster.