【摘要】 新冠肺炎疫情迅速蔓延,大量患者涌入医院,医务人员忙于一线救治工作,导致病历质量存在较大安全隐患。为保障病历质量,确保病历信息准确、及时、有效,同济医院迅速启动应急机制,包括编制新冠肺炎入院记录,制作电子病历操作流程手册,推进无纸化病历进程,优化环节管控规则,加强督查等。联合管控措施的实施,提高了病历书写效率与准确性,无纸化病历符合疫情防控需求,有效提升了病历书写质量。更多还原

【Abstract】 With the spread of COVID-19,a large number of patients were flooding in,and medical personnel were busy with first-line treatment,leading to safety risk in the quality of medical records.In order to ensure the quality of medical records,and ensure the accurate,timely and effective medical records information,the emergency response mechanism should be promptly started,including the formulation of COVID-19 admission records,the production of electronic medical records operating process manual,the promotion of paperless medical records,the optimization of management rules,and the strengthening of supervision.The implementation of joint management and control measures has improved the efficiency and accuracy of medical record writing.Paperless medical records meet the needs of epidemic prevention and control,and effectively improve the quality of medical record writing.更多还原