结构化电子病历的应用及问题  

Application and problems of structural e-medical records

作　　者：冯志香[1] 

机构地区：[1]兰州军区乌鲁木齐总医院干部病房干五科,乌鲁木齐市830000

出　　处：《中国病案》2009年第11期23-23,22,共2页Chinese Medical Record

摘　　要：目的积极应用结构化电子病历,努力提高病案质量。方法分析病案在防范医疗风险中的作用,结构化电子病历的优、缺点,及电子病历需完善之处。结果电子病历是临床信息化建议和发展的需要,医务人员应积极支持结构化电子病历系统的应用。结论病案质量体现医疗质量和技术水平,医护人员应重视电子病历的临床应用,电子病历的监控体系尚待完善。Objective To improve medical records quality by applying structural emedical records. Method Analyzing the role of medical records in preventing medical risks, advantages and disadvantages of structural e-medical records as well as what need to do to improve e- medical records, Results Since e- medical records are necessary to clinical information suggestions and development, medical staffs should actively support application of structural e - medical records system. Conclusion As medical records quality reflects medical quality; medical staffs should pay attention to clinical application of e- medical records. But, the monitoring system of e- medical records needs further improvement.

关 键 词：结构化电子病历 病案质量 

分 类 号：R197.324[医药卫生—卫生事业管理]