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对门诊电子病案信息的连续性、可及性和安全性进行研究。通过对JCI评审标准的理解以及在JCI认证准备过程中的实践和体会,找出门诊电子病案实际应用中的不足。阐述以第五版JCI标准为指导对门诊电子病案界面、内容及功能等方面持续改进的对策,通过门诊患者预检筛查确定初始评估项目,另设门诊病案小结及门诊病案概述,划分医务人员对门诊病案系统查阅和操作权限,论述整改后门诊病案系统的优势,并提出后JCI时代门诊电子病案需要进一步探讨的问题。
The continuity, accessibility and safety of outpatient electronic medical records are studied. Through the understanding of JCI accreditation standards and the practice and experience in JCI accreditation preparation process, this paper finds out the shortcomings in the practical application of outpatient electronic medical records. The fifth edition of the JCI standard as a guide to the outpatient electronic medical records interface, content and function of continuous improvement measures, through outpatient pre-screening screening to determine the initial assessment of the project, the other set out summary of outpatient medical records and outpatient medical records, the division of medical personnel On the outpatient medical record system access and operation authority, discusses the advantages of the outpatient medical record system after the rectification, and puts forward the questions that need to be further explored in the outpatient electronic medical record after the JCI era.