网上电子病案检查的优越性和局限性  

The Superiority and Limitation of On-line Examination on Computer-based Patient record

作　　者：杨翔宇[1] 高艳华[1] 霍小青[1] 王考庆[1] 刘芳[1] 刘克新[1] 

机构地区：[1]解放军总医院病案科

出　　处：《中国病案》2006年第5期26-28,共3页Chinese Medical Record

摘　　要：解放军总医院自2000年开始使用电子病案,同时使用计算机网络对病历进行实时质量监控,结果显示网上电子病案检查具有省时省力、方便快捷、及时发现在案病历内涵缺陷、提高工作效率的优越性,但对于拷贝病历内容和打印签名的真实性难以确定以及难以控制对病历的修改等。文章还针对其局限性,提出了一些如何提高网上电子病案质量的措施。Computer-based Patient record （CPR） has been used in Chinese PLA General Hospital since 2000, meanwhile, network real-time quality supervision was established. It is obvious that on-line examination on CPR has much superiority including time saving, convenient, finding CPR content default in time and promoting work efficiency. But in this supervision system, it is difficult to distinguish the authenticity of the copied records and the signature on printed documents, and monitor records modified. Aiming at the above limitation, we advanced some the quality online CPR management.

关 键 词：电子病案 质量管理 网上检查 缺陷 对策 

分 类 号：R197.324[医药卫生—卫生事业管理]