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机打病案是指应用文字处理软件编辑生成并打印的病案,是电子病案的前奏,它超越传统病案的模式,提高了病案书写的效率且字迹清晰,但它强大的复制功能及安全性等问题,给病案管理带来新的挑战。机打病案常见问题如反复复制、模板设计不规范、机打与手写混合现象等等。应建立机打病案相关制度,对进行机打病案的人员提出准入要求,并实施多层次、多环节的病案质量监控。
Machine-borne illness refers to the application of word processing software to edit the generated and printed medical records, which is the prelude of electronic medical records. It surpasses the traditional pattern of medical records and improves the efficiency of medical records writing with clear writing. However, its powerful replication and security issues , Bringing new challenges to the medical record management. Machine cases such as duplication of common problems, template design is not standardized, mixed machine and handwriting phenomenon and so on. The relevant system of machine-building medical records should be established, the requirements for access to computer-based medical records should be established, and multi-level and multi-link medical record quality control should be implemented.