摘要
在初步运行电子病历和新版首页过程中,病历书写中存在许多缺陷,本文通过对70份归档病历缺陷进行统计、分析,发现病案首页缺陷比较严重。针对不同缺陷,本文从人员培训、环节质控、奖惩制度三方面提出相应的整改措施。
During the first practice process of electronic medical records and front sheet of medical record , there is a lot of defaults in the quality of electronic medical records. Statistics and analyze the defaults of 70 medical records , the defaults of front sheet of medical records is serious , from different defaults , we should put forward appropriate improving measures involving in staff training , procedure quality , rewards and punishment.
出处
《内蒙古中医药》
2013年第28期76-77,共2页
Inner Mongolia Journal of Traditional Chinese Medicine
关键词
电子病历
病案首页
缺陷
整改措施
Electronic medical record
Front sheet of medical record
Defaults
Improving measures
