【作者】 高兴芳； 艾庆丽；

【机构】 延安大学附属医院病案统计室；

【摘要】 电子病历是使用医疗信息系统记载检查、诊断、治疗、护理等医疗活动有关资料,要进行分级、分层的质量控制;电子病历软件必须具有专业的质量控制功能提示、督促、逻辑关系稽核;书写时的质量控制,正在运行病历的环节质量控制是重点,一定要将所有看到的、触摸到的和听到的及时如实详细的描述,不合格的病历将需要修改完善。医师打印完成后,科室不能修改和书写;终末内涵质量控制,电子病历与纸质病历不相同,质控科的专家可以随时随地抽查正在运行的病历,对重点科室、重点疾病、重点医师重点抽查,随时反馈意见,及时完善,每月汇总对比电子病历内涵质量的提高趋势,利用专项通报公布信息,必要时可以奖优罚劣,一定能提高电子病历的质量。更多还原

【Abstract】 The EHR is a record that uses medical information system to save examination,diagnosis,treatment,care and other medical activities relevant information.And EHR can automatically make grading,layered quality control to the saved information.The EHR software must have professional quality control function and check,promote the information.The key point of this is the quality control when saving the information.The EHR should save all the things that to see,touch and hear.The unqualified EHR needs fixed to qualify.After the EHR is finished by doctor,the department can not modify and write it again.About the final step of EHR,the expert can check all the running EHR anytime and anywhere then give some feedback to let the doctor complete the EHR.This can makes the EHR have a high quality.更多还原