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电子病案常见质量缺陷包括病人基本资料缺漏,出院诊断选择错误,病程记录拷贝现象严重,诊断及鉴别诊断分析过于简单,病案过于框架化简单化。影响电子病案质量主要原因包括病案书写模式的改变,医师的综合素质能力,医务人员工作责任心,医务人员法制观念,医院重视程度。提高电子病案质量的对策包括加强医师规范化培训,建立电子病案的评审标准,确立以环节质控为主的实时质控及专家评审制度,定期举行电子病案质量检查与质量讲评。
The common quality defects of electronic medical records include the omission of basic data, the wrong choice of diagnosis, the seriousness of copying and copying of the course records, the simplification of diagnosis and differential diagnosis, and the simplification of medical records. The main reasons that affect the quality of electronic medical record include the change of medical record writing mode, the physician’s overall quality and ability, the responsibility of medical staff, the legal concept of medical staff, and the importance of the hospital. The measures to improve the quality of electronic medical record include strengthening standardized training for physicians, setting up evaluation standards for electronic medical records, establishing real-time quality control and expert review system based on link quality control, and regularly conducting electronic medical records quality inspection and quality review.