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抽查我院3年来住院电子病案,发现在复制病历、粘贴病历时出现姓名、年龄、病变部位粘贴错误;使用电子病历模版时出现同病种患者记录内容雷同;处理医嘱时间和电脑后台记录时间不一致等问题。通过对上述问题进行分析,探讨改进病案书写质量的措施。提出采取完善制度管理,上级医师对下级医师书写的病案进行审签;并组织法律法规、病历书写等相关培训;增强法律意识、加强网络建设等相应措施,准确的把握病案书写质量的各个环节,确保电子病案质量的稳定和提升。
Check the hospital for three years in hospital electronic medical records and found that in the replication of medical records, paste medical records appear name, age, paste the wrong parts of the lesions; the use of electronic medical record templates with patients with the same type of records the same content; processing time inconsistent with the computer background recording time And other issues. Through the analysis of the above problems, to explore measures to improve the quality of medical records writing. Proposed to take a sound system of management, the higher physicians to lower physician written medical records for the trial; and organize laws and regulations, medical records writing and other related training; enhance legal awareness and strengthen network construction and other appropriate measures to accurately grasp the quality of medical records writing all aspects, Ensure the stability and promotion of the quality of electronic medical records.