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目的通过对住院电子病历在临床中的应用,探讨住院电子病历在就医诊疗中使用的必要性和可行性。方法阐述住院电子病历与传统手写病历相比的优越性及存在的问题。结论电子病历提高了医生书写效率、书写质量,降低了错误病历发生率,改善了服务质量。尽快确认电子病历的合法性,解决法律安全问题,加快建立完善的电子病历系统,这将是医院管理的一大进步,值得发展和推广。
Objective To study the necessity and feasibility of using electronic medical record in hospital for medical treatment through the application of electronic medical records in the clinic. Methods The advantages and problems of in-hospital electronic medical records compared with traditional handwritten medical records were expounded. Conclusion Electronic medical records improve doctor writing efficiency, writing quality, reduce the incidence of false medical records, improve the quality of service. As soon as possible to confirm the legitimacy of electronic medical records to solve legal security issues and accelerate the establishment of a sound electronic medical record system, which will be a major step forward in hospital management, deserve to develop and promote.