数字化医院提高电子病历质量的方法  

The digital hospital countermeasure on improvement of electronic medical records

作　　者：王炳胜[1] 王景明[1] 石德光[1] 张立新[1] 李德炳[1] 肖静[1] 李勇[1] 张渊弘[1] 

机构地区：[1]解放军第251医院,河北张家口075000

出　　处：《中国医院管理》2008年第8期39-40,共2页Chinese Hospital Management

基　　金：全军医学科学技术研究"十一五"计划课题(06L007).

摘　　要：电子病历是数字化医院的重要标志之一,其质量至关重要。提出了电子病历目前存在的问题,有针对性地提出解决对策,包括增加电子储贮内容,力争与纸质病历相同;强化规章制度管理,确保电子病历安全性;提高电子病历"三性",最大限度保障法律地位;定期维护相关数据,满足"以人为本"要求;加大质量监管力度,全面提升病案质量。只有电子病历质量提高,医院方能健康全面发展。Electronic medical record （EMR） is an important indicator for the digital hospital, which quality also is very important. It not only described current problems of EMR, but also proposed corresponding measures. The measures included that increasing electronic data content to be identical with traditional medical records, enhancing rules and regulations management to safeguard its security, strengthening EMR＇s validity, rationality and correlation to provide the legal guarantee as more as possible, Maintaining relevant data regularly to meet needs of ＂human-oriented＂, reinforcing the supervision power of quality to improve the quality of medical records.The hospital would realize sustainable development, only if the quality of EMR was improved.

关 键 词：数字化医院 电子病历 质量 方法 

分 类 号：R197.324[医药卫生—卫生事业管理]