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使用电子病案模板减轻了临床医师书写病案的工作量。然而,它倒转了先查问再诊断的临床思维顺序,也为症状与体征的漏查“提供”了方便。解决这一问题的方法是将住院病案疾病诊断模板的出现时间推迟到诊断条目输入之后,并将模板出现后的病案修改痕迹作为病案质控的依据。
Using electronic medical record templates reduces the workload of clinicians writing medical records. However, it reverses the order of clinical thinking to ask again for diagnosis and “provides” convenience for missed investigations of symptoms and signs. The solution to this problem is to postpone the appearance time of the inpatient medical record diagnosis template to the entry of the diagnostic item, and use the trace of the medical record after the template appears as the basis for quality control of the medical record.