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电子病案在许多医院逐渐开始推行,给临床工作带来了极大方便,利于病历书写的规范化、标准化,但同时也带来了新的问题,特别是在电子病历使用初期,这些问题严重影响了病历质量。本文通过我院应用电子病历系统二年多出现的问题,提出现阶段电子病案的质量管理重点是基础质量管理,应开阔思路,丰富基础质控内容,加强全面质量管理。
Electronic medical records have gradually begun to be implemented in many hospitals, which has brought great convenience to clinical work and facilitated the standardization and standardization of medical record writing. However, it has also brought new problems, especially in the early stages of the use of electronic medical records. These problems have seriously affected Medical record quality. This article through the application of electronic medical records system in our hospital for more than two years, mentioning the emergence of electronic medical records in the emerging stage of quality management is the foundation of quality management, should broaden their thinking, to enrich the basic quality control content, and strengthen overall quality management.