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目的探讨病案管理由纸质的传统模式向电子病案的现代化模式转变过程中存在的利弊问题,以便制定相应的制度,从而加强质量管理及提高病案利用率。方法观察分析由传统纸质病案向电子病案转变过程中出现的问题。结果病案管理流程简化,医疗工作的效率提高;但是由于法律上的空白,导致纸质病历的继续存在。结论加强病案及医护人员计算机操作能力的培训,提高责任意识及法律意识,强化职能部门对病案环节质量管理。
Objective To explore the pros and cons of medical record management from the traditional paper mode to the modern one of electronic medical record in order to make the corresponding system so as to strengthen the quality management and improve the medical record utilization rate. Methods To observe and analyze the problems arising from the transition from traditional paper medical records to electronic medical records. Results The medical record management process was simplified and the efficiency of medical work was improved. However, due to the legal gaps, the paper medical records continued to exist. Conclusion The training on medical records and medical staff’s computer operation ability should be strengthened to raise the sense of responsibility and legal awareness and to strengthen the functional departments’ quality management of medical records.