摘要
通过计算机网络系统实时对动态病案质量进行审核和质量监控。重点监控电子病案环节质量,剖析病案书写中的问题,提醒医师重视诊断、用药、疗效分析的书写;有助医师明确诊断,减少医疗缺陷。注重监控三级医师对电子病案的检审;监控电子病案模板运行应用,在实践中不断完善无纸化电子病案。严格的权限管理,使医护人员职责清晰、责任心增强、工作效率提高。网络监控方便、快捷;规范了医疗行为;提高了病案书写质量,避免缺陷病案,减少医疗纠纷的发生,保证病案的安全性、真实性、完整性,为探索病案质量管理在网络环境下发展模式,最大限度发挥病案内在价值,提供有利依据。
Dynamic medical records quality are evaluated and monitored real-timely by computer network system. We focus on EMR segment quality and analyze the writing problems in medical records with reminding physicians to write diagnosis, medication, treatment analysis which can help them to definite diagnosis and to reduce medical defects for developing internal value of medical records in a maximum way. We pay attention to monitor tertiary doctors＇ examination; the strict authority management can help them make dear responsibility and work efficiency strengthening. EMR tem- plate application is monitored for continually perfecting non- paper EMR during practice. Network monitor is convenient and rapid which standardizes medical behavior and improves writing quality of medical records with reducing defects medical records and the medical tangle and making sure the safe- ty, truth and completeness of medical records. It provides benefit basis for exploring development mode of medical records management under the net- work environment.
出处
《中国病案》
2012年第11期22-23,共2页
Chinese Medical Record
