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随着医院现代化管理的进程对电子病案的管理提出了新的标准和要求。笔者对病案质量管理各环节中出现的常规病案缺陷及相关因素进行分析。强调电子病案控制的重点在于对环节质量控制,网上实施监控提出病案环节质量管理应与终末质量控制密切联系,并把环节质量制度化、规范化贯穿落实整个病案管理过程中的观点。
With the process of modern hospital management, new standards and requirements have been proposed for the management of electronic medical records. The author analyzes the defects of conventional medical records and related factors in the various aspects of the quality management of medical records. Emphasis on the importance of electronic disease control lies in the quality control of the link, the implementation of online monitoring and control of the quality of the disease link should be closely linked with the final quality control, and the quality and standardization of the link throughout the implementation of the entire medical record management point of view.