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目的探索电子病案质量管理的有效方法,提高电子病案质量。方法分析电子病历书写中出现的问题,指出容易产生医疗纠纷的原因。结果针对电子病案在医疗纠纷诉讼中的重要作用,提出在电子病案的书写过程中要做到真实、及时的反映医疗行为,从而减少医疗纠纷的发生。同时还应在技术层面对电子病案加强监管。结论加强电子病案质控管理是减少医疗纠纷的重要因素。
Objective To explore effective ways to improve the quality of electronic medical records and to improve the quality of electronic medical records. Methods Analyze the problems that appear in the writing of electronic medical records and point out the reasons that cause medical disputes easily. The results aiming at the important role of electronic medical records in litigation of medical disputes, and putting forward that it should reflect the medical behaviors in a true and timely manner in the writing of electronic medical records so as to reduce the occurrence of medical disputes. At the same time, there should be more technical regulation of electronic medical records. Conclusion Strengthening the quality control of electronic medical records is an important factor in reducing medical disputes.