摘要
对休养员疗养进行记录的电子病案进行网上检查和归档后的随机抽查发现存在过分依赖复制、粘贴和拷贝,书写不及时、时间不准确,打印归档不及时等问题。主要原因是医务人员责任心不强,法律意识淡漠,质控力度不够。采取针对性措施:强化责任意识,完善病案管理制度,加强法律法规意识,完善电子病案监控功能,才能提高电子病案的质量。
Some problems such as depend on copy, paste and copy, writing not timely, time is not accurate and print f＇de not timely, etc. were found by online inspection and random inspection. The main reasons were the sense of responsibility is not strong, legal consciousness indifference, and quality control is not strong enough. We should strengthen the responsibility consciousness, perfect medical record management system, and strengthen the consciousness of laws and regulations and perfect electronic medical record monitoring function to improve the quality of the electronic therapy
出处
《中国病案》
2013年第1期49-50,共2页
Chinese Medical Record
关键词
电子病案
质量问题
对策
Electronic medical record
Quality problem
Countermeasures
