【摘要】 目的分析1020份护理电子病历记录的缺陷,探讨提高护理电子病历质量的对策。方法从2010年1月-12月在本院随机抽查了1020份护理电子病历,对存在的缺陷进行分析,并提出干预对策。结果发现护理记录不及时,漏手写签名或替代、模仿他人手写签名,记录不完整,未体现专科特点,缺乏连续性,记录不一致等缺陷。结论加强对护士的法律意识及护理电子病历书写知识培训,强化病历安全系统管理及监督,安装电子移动工作站,实行病历环节质量控制等,是减少缺陷和提高病案质量的有效方法。更多还原

【Abstract】 Objective To analyze defects of 1020 nursing EMR,and to discuss how to improve the quality of nursing EMR.Methods Checking 1020 copies of nursing EMR randomly from January 2010 to December 2010.Analyzing shortcomings,and proposing intervention measures.Results Some defects were found such us not timely,replace or copy handwritten signature,incomplete,Not reflect specialized subject characteristics,lack of continuity,inconsistent.Conclusion Some measures should be taken to reduce defects and improve the quality which are strengthening the legal consciousness and writing knowledge training,strengthening the medical records safety management and supervision system,installing electronic mobile workstation,taking medical records link quality control.更多还原